Evaluation of the overall program effectiveness of HIV-related intervention programs in a community in Sichuan, China

Do HIV prevention interventions in Asia lead to increase in condom utilization?: A meta-analysis study

This meta-analytic review synthesizes the findings of published independent studies that assessed the effectiveness of HIV prevention interventions in promoting condom usage in Asia. We focused on 20 studies that used randomized control studies to establish whether HIV prevention interventions lead to increased condom utilization. As compared with the average control group client, we found that 68% of the clients who participated in an intervention group increased their condom usage. The effectiveness of HIV prevention intervention is not related to country and rural-urban contexts, to male-female samples, to the type of outcome measured, or the timing of the latest follow-up assessment. The implications of these findings are that policy-makers, health administrators, and international donors should view behavioral HIV prevention interventions as an effective approach through which to increase condom usage in order to reduce the HIV infection rate in Asia.

Indigenous HIV Prevention Beliefs and Practices Among Low-Earning Chinese Sex Workers as Context for Introducing Female Condoms and Other Novel Prevention Options

New interventions to reduce HIV and sexually transmitted infections (STI) among female sex workers are introduced into the context of women's existing prevention beliefs and practices. These indigenous practices affected implementation of our program to introduce female condoms to women in sex-work establishments in southern China. We used ethnographic field observations and in-depth interviews to document common prevention methods women reported using to protect themselves before and during intervention implementation. Individual, sex-work establishment, and other contextual factors, including sources of information and social and economic pressures to use or reject prevention options, shaped their perceptions and selection of these methods and affected adoption of female condoms as an additional tool. Efforts to improve uptake of effective prevention methods among low-income sex workers require attention to the context and spectrum of women's HIV/STI prevention practices when introducing innovations such as female condoms, microbicides, pre-exposure prophylaxis pills, and others, as they become available.

Impact evaluation of a community-based intervention to reduce risky sexual behaviour among female sex workers in Shanghai, China

Background

Female sex workers (FSWs) are at risk for sexually transmitted infections (STIs), including HIV. We implemented an HIV/STI preventive intervention among FSWs in Shanghai that aimed to increase condom use, improve HIV knowledge, and reduce STI and HIV incidence.

Methods

From six districts in Shanghai, 750 randomly selected venue-based FSWs were allocated to either a behavioural intervention or control group. In the intervention and control groups, 221 and 278 participants, respectively, had at least one follow-up at three or six months. In analysis, we randomly selected 57 lost to follow-up cases in the intervention group and imputed baseline values to equalize the arms at n = 278 (74.1% follow-up rate in each group). The impacts of the intervention on condom use, HIV/STI risk perception and knowledge, and STI incidence were assessed using either a logistic or linear model, adjusting for the baseline measure of the outcome and venue type.

Results

The intervention improved consistent condom use with any partner type in the previous month (AOR = 2.09, 95% CI, 1.43-3.04, p = 0.0001). Consistent condom use with clients in the three most recent sex acts increased in both arms, and with primary partners in the intervention arm, but there was no difference between groups after adjusting for baseline condom use and venue type. There were no differences in cumulative incidence of any STI (i.e., chlamydia, gonorrhoea, syphilis) between groups. HIV transmission knowledge (p = 0.0001), condom use skill (p = 0.0421), and self-efficacy for using condoms (p = 0.0071) were improved by the intervention. HIV-related stigma declined (p = 0.0119) and HIV and STI risk perception were improved (4.6 to 13.9%, and 9.4 to 20.0%, respectively). The intervention was associated with these improvements after adjusting for the baseline measure and venue type.

Conclusion

Following a preventive intervention among Shanghai FSWs, our findings demonstrate that a simple, community-based educational intervention improved overall condom use, HIV and STI knowledge, and attitudes in relation to HIV/AIDS. The intervention should be implemented widely after tailoring educational materials regarding condom negotiation with different partner types (i.e., commercial sex clients and primary partners).

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1439-5) contains supplementary material, which is available to authorized users.

A randomized controlled trial evaluating the efficacy of a theory-based intervention promoting condom use among Chinese monogamous female sexually transmitted infection patients

BACKGROUND

Chinese monogamous women may contract sexually transmitted diseases (STD) from their sole male sex partner, but these women do not have high self-efficacy in negotiating about condom use with their regular sex partners.

PURPOSE

We aim to investigate the relative efficacy of a theory-based and clinic-based cognitive behavioral intervention versus a control intervention in increasing prevalence of condom use with their male sex partner among Chinese monogamous female sexually transmitted disease patients.

METHODS

A randomized controlled trial (RCT) was conducted. Participants were randomly allocated into the intervention group (n = 88) or the control group (n = 88). All participants were phone interviewed at baseline and at 2 and 3 months after completion of the baseline survey. The three-session group intervention was based on the information-motivation-behavioral skills (IMB) model. Participants of the control group were provided with educational pamphlets. The primary outcome was consistent condom use in the last month. Relative risks were calculated, and multiple logistic regression models were fit.

RESULTS

As compared to the control group, the intervention group reported higher prevalence of consistent condom use with the sole male sex partner in the last month at month 2 (75.3 versus 59.8%, RR = 1.26, 95% CI = 1.01, 1.57) and month 3 (77.8 versus 54.6%, RR = 1.42, 95% CI = 1.13, 1.80), whilst the baseline between-group difference was statistically non-significant. Some other secondary outcomes such as "intention to request condom use in the next month even if the sexual partner dislikes using condoms" were also statistically significant. Furthermore, the majority (94%) of the intervention group members were satisfied with the intervention.

CONCLUSIONS

The theory-based intervention is potentially efficacious, but the follow-up period was relatively short. Large-scale randomized clinical trials and subsequent translational research are greatly warranted in the future.

Condoms used but sex not well protected

Condom use is often equated to safer sex. The prevalence of condom use during sex work among female sex workers (FSW) in China is high. Condom use, however, co-exists with condom failure and improper use and hence risk of HIV transmission. In a cross-sectional study, we interviewed 195 FSW in Shenzhen, China. The prevalence of condom use in the last episode of sex work was 97.4 %, However, respectively 53.8 and 86.2 % had experienced at least one condition of condom failure that may lead to genital contact (wearing condoms after penetration, condom breakage/slippage, condoms removed by clients) and at least one condition of improper condom use (not removing air from the tip of the condom, not pulling it down to the root of penis and not choosing good quality condoms). Factors of individual level (e.g. never choosing high quality condoms for sex work), inter-personal level (e.g. agreement to have unprotected sex if fond of clients or paid more) and environmental/structural level (e.g. non-availability of condoms) were associated with various types of condom failure and improper use. Although HIV prevention interventions have increased prevalence of condom use among FSW, the risk of HIV transmission may still be high as "unsafe" sex due to condom failure and improper use is prevalent. Interventions promoting safer sex need to address such issues and take socio-ecological factors into account. Condom use during sex work is not equivalent to well protected sex as the protective effects could be compromised by frequent condom failure and improper use.

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.

The Global HIV Archive: Facilitating the Transition from Science to Practice of Efficacious HIV Prevention Interventions

This paper describes the development, content, and capabilities of the online Global HIV Archive (GHA). With the goal of facilitating widespread adaptation and appropriate use of efficacious HIV prevention programs throughout the globe, GHA has: first, expanded and updated the search for HIV prevention programs originating in low-resource countries; second, identified those meritorious HIV prevention programs meeting established efficacy criteria of technical merit, replicability, and positive outcomes; third, prepared both implementation and evaluation materials from the efficacious programs for public use; fourth, developed interactive wizards or capacity-building tools to facilitate appropriate program selection, implementation, and adaptation; and, fifth, made the efficacious programs and accompanying wizards available to health practitioners throughout the globe in both printed and online formats.

Reducing STD/HIV stigmatizing attitudes through community popular opinion leaders in Chinese markets

Reducing STDs and HIV/AIDS incidence requires campaigns designed to change knowledge, attitudes and practices of risky sexual behavior and its consequences. In China, a significant obstacle to such changes is the stigma associated with these diseases. Thus one campaign intervention strategy is to train credible community popular opinion leaders to discuss these issues in everyday social venues. This study tested the effectiveness of such an approach on reducing HIV/AIDS stigma, across two years, from a sample of over 4500 market vendors, in three conditions. Results showed an increasing growth in market communication about intervention messages, and concomitant declines in stigmatizing attitudes, across time, with the greatest changes in community popular opinion leaders, significant changes in intervention non-opinion leaders, and little change in the control markets.

HIV/sexual risk reduction interventions in China: a meta-analysis

The current study was a meta-analysis of the efficacy of educational, psychosocial or behavioral interventions that were conducted in China to promote HIV/sexual risk reduction. A total of 26 intervention studies qualified for the meta-analysis. Outcome variables for which effect sizes were calculated included condom use with different types of sexual partners, HIV/AIDS knowledge, condom use knowledge, intentions of condom use, condom use self-efficacy, and others. Mean weighted effect sizes were calculated for each outcome measure across reviewed studies; effect size for each outcome measure was weighted by their inverse variance; fixed effects and random effects meta-analytic procedures were used. The Q statistic was used to examine whether the effect sizes were homogeneous in nature and moderating analysis (i.e., the Q(b) statistic) was used to compare the effect sizes of intervention studies that were different in a number of categorical variables. The reviewed interventions were successful in improving HIV knowledge (d=0.706), condom use knowledge (d=0.620), attitudes toward people living with HIV/AIDS (PLWHA; d=0.625) and in increasing condom use with regular partners (d=0.477), condom use with casual partners (d=0.444), general condom use (d=0.408), and condom use self-efficacy (d=0.584) among target audiences. In addition, moderating analyses on three most examined variables, including HIV knowledge, condom use, and attitudes toward PLWHA, demonstrated that interventions that reported the conduction of formative research and process evaluation, that were peer-led, and that included only one follow-up were more likely to report a positive impact on condom use behavior among target audiences (p<0.001), HIV knowledge (p<0.001), or attitudes toward PLWHA (p<0.001).

How likely are HIV-positive female sex workers in China to transmit HIV to others?

BACKGROUND

Female sex workers (FSW) are highly marginalised and HIV-positive FSW are under a double stigma. No study has assessed the likelihood of secondary transmission via HIV-positive FSW in China.

METHODS

A total of 199 FSW who injected drugs were recruited by snowball sampling, and 158 non-injecting FSW were recruited from sex service establishments by convenience sampling in Dazhou, China. All participants were interviewed anonymously using a structured questionnaire.

RESULTS

If found to be HIV-positive, 11.7% of the participants would continue working as FSW, 24.6% would not care about transmitting HIV to others, 18.8% believed that they would eventually spread HIV to others and 9% would take revenge by spreading HIV to others. In multivariate models, factors associated with ≥ 1 of the four aforementioned perceptions (42.0%) included drug use (odds ratio (OR)=1.82-3.26, P<0.01), perceived discrimination towards people living with HIV and AIDS in China (OR=2.03, P<0.05) and perceived inaccessibility to medical treatments if diagnosed as HIV-positive (OR=2.30, P<0.01); the reverse was true for use of HIV-related services (OR=0.53, P<0.05) and suicidal intentions if found to be HIV-positive (OR=0.42, P<0.05).

CONCLUSIONS

Improvement of the social, care and medical environment of HIV-positive FSW is likely to reduce secondary transmission via HIV-positive FSW. Special attention should be given to FSW who inject drugs.

HIV/STI prevention interventions targeting FSWs in China: a systematic literature review

A rapid increase in heterosexual transmission of HIV and a high prevalence of sexually transmitted infections (STIs) in China signals potential outbreaks of generalized epidemics. A large proportion of heterosexual transmission has been through commercial sex; thus, millions of female sex workers (FSWs) and their clients play a critical role in the country's HIV/STI epidemics. A number of prevention interventions targeting FSWs have been implemented in response to changes in policy toward HIV as well as growing epidemics. This study reviews existing HIV/STI prevention interventions studies targeting FSWs in China. A total of 25 studies (28 articles) were identified from English and Chinese journal databases. Most studies recruited FSWs from entertainment establishments and had small sample sizes of less than 400. A majority employed a simple pre-post design with an open cohort, none applied a randomized controlled trial, and only two studies had a quasi-experimental design. Venue-based knowledge education and condom promotion represented the typical intervention approach. Some adapted internationally validated programs such as Voluntary Counseling and Testing and 100% Condom Use Programs (CUP), but no scale-up data were reported. Significant intervention effects were reported in most studies, especially increases in HIV/STI-related knowledge and condom use rates. Of the nine studies reporting STI rates, the results were mixed; some even reported increased STIs despite higher condom use. We call for more HIV/STI interventions targeting FSWs in China, particularly, interventions with rigorous design and externally validated measures, and more diversity in intervention programs including biomedical and structural interventions as well as innovative intervention delivery. We also advocate that effective intervention programs be translated into sustainable policies and programs that could have an impact on China's HIV and STI epidemics.

Sexual mixing and condom use with different types of sex partners among non-institutionalized sexually active female injecting drug users in Sichuan, China

Behavioral surveillance data of 1422 sexually active female injecting drug users (IDU) in Sichuan China were analyzed. The prevalence of syringe-sharing was 43.5%. Respectively, 59.0%, 38.5% and 55.7% had regular, non-regular, and commercial sex-partner (RP, NRP, and CSP); 44.3% had multiple types of sex partners; 23.6 and 36.2% of those with RP had NRP and CSP. The prevalence of unprotected sex (last episode) with RP, NRP and CSP were respectively 75.4%, 50.7% and 39.3%; these three variables were associated with each other and with syringe sharing (univariate OR = 1.58-30.13). About 85% of the participants had attempted quitting drug use; the experience was not associated with condom use. HIV voluntary counseling and testing was associated with lower likelihood of unprotected sex with RP, NRP and CSP (multivariate OR= 0.44-0.60); the coverage was only 40.7%. Potential bridging of HIV transmission from IDU to non-IDU populations is a serious concern.

Changes in risk behaviours and prevalence of sexually transmitted infections following HIV preventive interventions among female sex workers in five districts in Karnataka state, south India

OBJECTIVES

To examine the impact of a large-scale HIV prevention programme for female sex workers (FSW) in Karnataka state, south India, on the prevalence of HIV/sexually transmitted infections (STI), condom use and programme coverage.

METHODS

Baseline and follow-up integrated biological and behavioural surveys were conducted on random samples of FSW in five districts in Karnataka between 2004 and 2009.

RESULTS

4712 FSW participated in the study (baseline 2312; follow-up 2400), with follow-up surveys conducted 28-37 months after baseline. By follow-up, over 85% of FSW reported contact by a peer educator and having visited a project STI clinic. Compared with baseline, there were reductions in the prevalence of HIV (19.6% vs 16.4%, adjusted odds ratio (AOR) 0.81, 95% CI 0.67 to 0.99, p=0.04); high-titre syphilis (5.9% vs 3.4%, AOR 0.53, 95% CI 0.37 to 0.77, p=0.001); and chlamydia and/or gonorrhoea (8.9% vs 7.0%, AOR 0.72, 95% CI 0.54 to 0.94, p=0.02). Reported condom use at last sex increased significantly for repeat clients (66.1% vs 84.1%, AOR 1.98, 95% CI 1.58 to 2.48, p<0.001) and marginally for occasional clients (82.9% vs 88.0%, AOR 1.22, 95% CI 0.89 to 1.66, p=0.2), but remained stable for regular partners (32%). Compared with street and home-based FSW, brothel-based FSW were at highest risk of HIV and STI, despite high levels of reported condom use.

CONCLUSIONS

This large-scale HIV prevention programme for FSW achieved reductions in HIV and STI prevalence, high rates of condom use with clients and high rates of programme coverage. Improved strategies to increase condom use with regular partners and reduce the vulnerability of brothel-based FSW to HIV are required.

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.

Declines in risk behaviour and sexually transmitted infection prevalence following a community-led HIV preventive intervention among female sex workers in Mysore, India

OBJECTIVE

To investigate the impact on sexual behaviour and sexually transmitted infections (STI) of a comprehensive community-led intervention programme for reducing sexual risk among female sex workers (FSW) in Mysore, India. The key programme components were: community mobilization and peer-mediated outreach; increasing access to and utilization of sexual health services; and enhancing the enabling environment to support programme activities.

METHODS

Two cross-sectional surveys among random samples of FSW were conducted 30 months apart, in 2004 and 2006.

RESULTS

Of over 1000 women who sell sex in Mysore city, 429 participated in the survey at baseline and 425 at follow-up. The median age was 30 years, median duration in sex work 4 years, and the majority were street based (88%). Striking increases in condom use were seen between baseline and follow-up surveys: condom use at last sex with occasional clients was 65% versus 90%, P < 0001; with repeat clients 53% versus 66%, P < 0.001; and with regular partners 7% versus 30%, P < 0.001. STI prevalence declined from baseline to follow-up: syphilis 25% versus 12%, P < 0.001; trichomonas infection 33% versus 14%, P < 0.001; chlamydial infection 11% versus 5%, P = 0.001; gonorrhoea 5% versus 2%, P = 0.03. HIV prevalence remained stable (26% versus 24%), and detuned assay testing suggested a decline in recent HIV infections.

CONCLUSION

This comprehensive HIV preventive intervention empowering FSW has resulted in striking increases in reported condom use and a concomitant reduction in the prevalence of curable STI. This model should be replicated in similar urban settings across India.