Upload
christopher-morton
View
215
Download
2
Embed Size (px)
Citation preview
Development of an Intervention for Clients of Female Sex Workers
TL Patterson, S Goldenberg,
S Semple, SA Strathdee University of California, San Diego
Clients of Female Sex Workers (FSWs)
• Sex work is driven by demand– 3 million FSWs worldwide, and growing
• Most studies focus on FSWs to the exclusion of male clients
• Clients of FSWs:– Risk becoming infected with STI
themselves– Infecting FSW with STI– Bridge to other sex partners (e.g. wives,
girlfriends, MSM)
Worldwide estimate of number of male clients of FSWs
Source: 78 national household surveys and other sources to estimate percentage of men who reported paying for sex in previous 12 months
In M
illio
ns
Sex Work in Tijuana, Mexico
• Sex work is regulated in many Mexican border cities, such as Tijuana
• ~ 9000 FSWs in Tijuana attract clients from Mexico and US
• Prevalence of HIV is 6% and rising among FSWs in Tijuana
• HIV prevalence 5% among
FSWs’ clients
Study setting: Tijuana, Mexico
Emerging HIV epidemic: 1/116 adults are HIV+1
Sex work: Draws local, U.S., international clients
Mobility: World’s busiest international land crossing
51. Iñiguez-Stevens, E., et al. (2009). [Estimating the 2006 prevalence of HIV by gender and risk groups in Tijuana, Mexico] [article in Spanish]. Gaceta Médica de México,145(3):189–195.
Source: CALTRANS
USA
MEXICO
• Impact of sex work depends on form, context, location1
• “Risk environment” 2
– Economic - incentives for risky sex– Policy - sex work regulation, condom
availability– Physical – venues– Social - interactions
with clients,
alcohol and drug use
6
Background
1. Harcourt C, Donovan B. The many faces of sex work. Sex Transm Infect 2005;81(3):201-6.2. Rhodes T. Risk environments and drug harms: A social science for harm reduction approach. International Journal of Drug Policy
2009;20(3):193-201.
Source: Wikipedia Commons, 2009
Source: Wikipedia Commons, 2007
Where did our work begin:Safer sex intervention for FSWs
• Study aim– Test a brief theory based
intervention designed for Mexican FSWs in Tijuana and Cd. Juarez
Source: Oralia Loza
Baseline Assessment
Mujer Segura
One 40-minute one-on-one Counseling Session
Six Month Assessment
Didactic Safer Sex
One 40-minute one-on-one Counseling Sessions
Study Design
Mujer Segura Counseling Topics*
Topic Description
Context of Unsafe Sex
Develop insights into motivations/triggers of unsafe sex. Set plan and goals for safer sex
Condom Use MI and skill-building to induce behavior change. Match counseling to individual’s stage of change
Negotiation of Safer Sex
MI and skill-building to teach negotiation skills to move participants into action
*incorporating motivational interviewing (MI) and social cognitive theory
7.7%
12.8%
0.0%
4.0%
8.0%
12.0%
16.0%
Any new STI
Pe
rce
nta
ge
of
Pa
rtic
ipa
nts
Intervention Control
RR = 1.66
p = .04
Intervention Effect on FSWs’ Incident STIs at 6-month
Follow-up
Incidence of HIV Infectionamong FSWs
Incident HIV
0
0.5
1
1.5
2
2.5
Intervention Control
Condition
Inc
ide
nc
e p
er
pe
rso
n
ye
ar
0
Conclusions• FSWs in the intervention arm significantly:
– reduced incident STIs/HIV– Increased the percent of time they used condoms with
clients
• But … this intervention puts the burden of safer sex on the sex worker when the clients are a significant part of the problem
• How do we develop an intervention for clients?
Pilot test materials and revise as needed
Conduct randomized controlled trial to
determine intervention efficacy
Conduct implementation study to enhance dissemination of
intervention to agencies and CBOs
Identify risk group Gather community support(Risk group, local, state & federal officials)
Conduct epidemiologic studies to determine if an individual
intervention is merited
Develop theory-based intervention with specific context and risk behaviors in mind and adapt to cultural context as
needed
Conduct qualitative study to understand the context of risk behavior
Revise intervention with stakeholders
Steps to developing a efficacious intervention for clients
14
Qual-Quant Study: Objectives and hypotheses
(1) To examine correlates of clients who meet FSWs in nightlife venues
(2) To investigate clients’ perspectives on venue-based risks and bridging
Source: Wikipedia Commons, 2007
Methods• Men recruited in Tijuana’s Zona Roja, 2008-09.
– paid/traded for sex with FSWs in previous 4 months – aged ≥18 years – from the U.S. or Mexico
• Participants underwent interviews and rapid testing for HIV and STIs.
• Recruited through jaladores• (touts) and street outreach
Methods: Study population and data sources
16
In-depth qualitative interviews (n=30)
Purposive sub-sample of male clients
Perceived HIV/STI risk
Condom use
Sex purchasing experiences
Social and structural factors (e.g., venues, paying more for unprotected sex)
Quantitative interviews(n=400)
Males≥ 18 who paid/traded for sex with a FSW in Tijuana, past 4 months
Surveys• Demographics, sexual behavior, substance use• Venues
Laboratory testing• HIV, Syphilis, Chlamydia, Gonorrhea
Methods: Variables• Dependent
– Met FSW in nightlife venue (i.e. bar, cantina, nightclub, or strip club)† (yes vs. no)
• Independent– Socio-demographics– Sexual behavior and substance use – Physical environment (lives in US vs. Mexico)– Social environment (e.g., client and FSW
alcohol use during sex†)– Policy environment (e.g., non-availability of
condoms as reason for unprotected sex) 17
†Refers to past 4 months
Table 1: Socio-demographic, behavioral, environmental and HIV/STIs among FSWs’ clients in Tijuana, 2008
Measure % who met FSW in nightlife venue (n=301)
% who did not meet FSW in nightlife venue (n=98)
Socio-demographics
Hispanic/Latino 80.1 78.6
Speaks English 81.7 77.6
Lives in Mexico 52.8 52.0
Years of education (median, IQR) 12 (9, 12)** 10 (7, 12)
Sexual behavior and substance use
Had unprotected sex with FSW† 55.1*** 35.1
Has ≥ 5 drinks when drinking 44.9*** 17.3
Risk environment
Offered extra money for unprotected sex 19.6** 8.2
Amount paid for sex in dollars (mean, IQR) 36.7 (20, 40)** 26.1 (20, 30)
Self reported STI† 19.4* 9.4 18
†Refers to past 4 months; ***p<0.001, **p<0.01, *p<0.05; °IQR: Inter-quartile range
Correlates of meeting FSWs in nightlife venues
• Ever offered FSW in Tijuana more money for unprotected sex– AOR: 2.65 (1.19, 5.93)**
• Binge drinking– AOR: 4.13 (2.30, 7.42)***
19
**p<0.001, **p<0.01, *p<0.05
Photo By: Oralia Loza
Qualitative Themes: venue-based HIV risks
• Clients described nightlife venues as high-risk:– Heavy alcohol consumption impairs judgment
• Courting rituals in nightlife venues• Binges, letting go of inhibitions
– Monetary incentives for unprotected sex in bars• Pressure from establishments to earn $
– Less enforcement of sex work regulations than on the street• Bar-based sex work less visible 20
Example: less enforcement of nightlife-based sex work
“I prefer the ones [girls] on the street who are controlled with the paperwork than the ones who aren’t… The girls on the strip there [the Callejon] constantly get the health workers asking for their cards [sex work permits]. You know, they got to be checked [tested for STIs/HIV], or they can’t work. So I would prefer to mess with those girls….”
21
Source http://www.ericrench.com/MEXICO/TIJUANA/NORTE/INTRO/index.htm 2011
What proportion of clients are potential bridgers?
Percent of 383 clients with wives/steady partners
134 (35%)
70 (52%)
Percent of 134 clients with wives/steady partners who
report unprotected sex
Social Cognitive Factors of Bridgers and Nonbridgers
OR3.78*
OR2.17*
OR7.75*
OR0.81
OR0.21*
Me
an
Sc
ore
* P<0.05
Factors Independently Associated with Bridging Behavior Among Male Clients
With Wives or Partners (n = 134)
Characteristic or Behavior
Adj OR 95% CI
Used drugs during sex with FSW, past 4 months
3.39* (1.40 – 8.23)
Ever offered FSW extra money to have sex without a condom
24.52* (3.08 – 195.4)
Sexual sensation seeking scale 4.28* (1.41 – 13.02)
* P<0.05
Factors Independently Associated with Bridging Behavior Among Male Clients
With Wives or Partners (n = 134)
Characteristic or Behavior
Adj OR 95% CI
Used drugs during sex with FSW, past 4 months
3.39* (1.40 – 8.23)
Ever offered FSW extra money to have sex without a condom
24.52* (3.08 – 195.4)
Sexual sensation seeking scale 4.28* (1.41 – 13.02)
Client (age 26): “Once they get the drugs in them, then they don’t give a damn about a condom. It’s all about the high and the money. The condom is not important.”
Factors Independently Associated with Bridging Behavior Among Male Clients
With Wives or Partners (n = 134)
Characteristic or Behavior
Adj OR 95% CI
Used drugs during sex with FSW, past 4 months
3.39* (1.40 – 8.23)
Ever offered FSW extra money to have sex without a condom
24.52* (3.08 – 195.4)
Sexual sensation seeking scale 4.28* (1.41 – 13.02)
Client age 23:“I am a risk junkie. It creates more excitement for me, makes it more euphoric. I figured that out about myself. The more prohibited things are, the more exciting it makes me feel….”
Conclusions• Clients are at risk of bridging HIV/STIs to FSWs and the
general population.
• Half of clients who have unprotected sex with a regular sex partner also report unprotected sex with FSWs
• Greatest risks posed by venues where:
– clients have more control– alcohol/drugs are used, and– high numbers of client are encouraged
• Cannot generalize findings from any one culture to another, but in this context, implications for interventions indicate: – Modifiable behaviors: drug and alcohol use– More difficult to modify: sensation seeking, misogyny
28
MACRO
Poverty, economic desperation
Immigration and deportation policies
Harm reduction policies
Incarceration
Access to health and social services
MICRO
Local social norms
Social isolation
Economic roles
Social networks
Unprotected sex
Substance use
HIV
Root causes
Proximal causes
Implications and suggested interventions
MACRO• Economic and social
support for clients• HIV/STI prevention and
testing, drug treatment services for clients
1. HIV Risk Environment framework, adapted from Rhodes, 2009
MICRO• Jalador peer education,
condom distribution• Counseling and support
for ciients
SUGGESTED INTERVENTIONSDRIVERS OF HIV VULNERABILITY1
Where are we now?
• Testing individual intervention for clients in Tijuana– Study design 200 receive Hombres Seguro,
200 didactic presentation; 6 and 12-mo FU• Implementation study of Mujer Segura in
12 cities in Mexico
Hombres Seguro Counseling
*incorporating motivational interviewing (MI) and social cognitive theory
STEP 1: Determine readiness for change, and build motivation for change
STEP 2: Explore participant’s attitudes toward condoms and unsafe sex
STEP 3: Assess high-risk situations, explore triggers of unsafe sex, and discuss coping with cravings and urges
STEP 4: Explore drug/alcohol use as triggers of sexual risk behaviors with FSWs: discuss harm reduction strategies
STEP 5 Identify barriers to unsafe sex with FSWs: make plans to overcome barriers
STEP 6: Condom skill-building exercise
STEP 7: Communication and safer sex practices & evaluation of roleplay
Collaboration• México collaborators M Gallardo, R. Lozada, C. Magis
• U.S. collaborators, A. Robertson
• Study Staff and Participants
• PREVENCASA A. C
• COMUSIDA A.C
• ISESALUD/CAPASITS
• Asociación de Bares and Hoteles
• Binational Committee on Human Rights
• Municipal Medical Services
• Volunteer bartenders, security guards
Acknowledgements
• UCSD CFAR International Pilot Grant to R. Lozada (UCSD CFAR is funded by NIH P30 AI036214)
• NIDA Grants: R01 DA029008;R01 DA023877-S1
• San Diego County Public Health Laboratory
Source: Shira Goldenberg
THANK YOU
For more information please contact:
Thomas L. Patterson
Department of Psychiatry
University of California San Diego
Email: [email protected]