Keeping up with the epidemic

Programme success leaves us with new challenges:

An evaluation of programmes for injecting sex workers

Background

• Some 90% of people living with HIV in our district are drug injectors

• We have harm reduction programmes that we believe are effectively preventing transmission among IDU

• The biggest risk for onwards transmission to non-injectors is from female IDU who sell sex

• We therefore aim to provide safe sex services for women who both inject and sell sex

Programme logic• Our programme aims to reach women who both sell sex

and inject drugs.• Entry points are finding injectors among sex workers as

well as identifying female IDU who sell sex• Outreach workers will distribute condoms to them, give

skills training to promote condom negotiation and use, and refer to STI services.

• We will train doctors and support clinics providing quality STI services.

• Female injectors who sell sex will increase their use of condoms and STI screening and treatment.

• The risk of STI and HIV transmission will fall

Data analysis plan Look at programme monitoring data to see if

programme is being delivered Programme and BSS data tell us if we are

reaching the target population Programme and BSS data tell us if the target

population is using the services BSS data tells us if the programme has an effect

Does behaviour changes over time? Do people with programme contact have different

behaviour than people who have no programme contact?

Biological surveillance data will show no rise in HIV

Outreach workers are getting condoms to both sex workers and IDU

项目分人群发放的安全套数(底区1督导评估资料, 2003-2005年)

0

2000

4000

6000

8000

10000

12000

14000

5-6 月，2003

7-9 月 10-12 月 1-3 月 2004 4-6 月 7-9 月 10-12 月 1-3 月 2005 4-6 月 7-9 月

# condoms distributed to FSW # condoms distributed to DU # condoms distributed to HIV +ve

And they seem to be doing an especially good job of reaching the women who both inject drugs and sell sex

最近一年收到免费安全套的暗娼, 不同吸毒状态Percent of women selling sex who received a free condom in the last year, by IDU status

(Site 1 BSS, 2003-2005)

38

68

94

53

86 84

0

10

20

30

40

50

60

70

80

90

100

2003 2004 2005

Per

cent

IDU No IDU

Condom use with clients has more than doubled among women who inject drugs and sell sex

% of women who sell sex using condoms with every client in the last month, by injecting status(Site 1 BSS, women who sell sex, 2003-2005)

64 64

79

32

86

71

0

10

20

30

40

50

60

70

80

90

100

2003 2004 2005

% u

sing

con

dom

s w

ith a

ll cl

ient

s la

st m

onth

Not IDU IDU

Skills training helps sex workers use condoms consistently, but even those with no skills training report high condom use

% of women who sell sex who used condoms with all clients last month, by whether they received skills training

(Site 1 BSS, women who sell sex, 2003-2005)

62

70

83

62 63 64

0

10

20

30

40

50

60

70

80

90

100

2003 2004 2005

Per

cent

no skills training skills training

Contact with outreach workers appears to have a bigger impact on STI screening behaviour

% of women who sell sex reporting free STI exam in the last year (BSS, Site 1, 2003-2004)

18

50

63

3

128

0

10

20

30

40

50

60

70

80

90

100

2003 2004 2005

Per

cent

No outreach Outreach

And the outreach is more effective for injecting sex workers than for non-injectors

% of women who sell sex who went for free STI exam, by injecting status and contact with outreach workers(Source: Site 1 BSS, 2003 - 2005)

3

139

14

47

64

29

70

59

00 0

0

10

20

30

40

50

60

70

80

90

100

2003 2004 2005Per

cen

t o

f w

om

en h

avin

g f

ree

ST

I ex

am i

n p

ast

6 m

on

ths

Not IDU, no outreach contact Not IDU, outreach contact IDU, no outreach contact IDU, outreach contact

So how are we doing？• We are distributing condoms

• Outreach workers are reaching injecting sex workers, who say they receive condoms

• Those reached by outreach are more likely to use condoms and go for STI screening, and the difference is greatest among injecting sex workers

…our programmes seem to be working

But…What are all those well-trained doctors doing？

# of STI doctors trained, FSW with outreach referrals to STI services and female clients at project STI clinics

(Programme monitoring data, Site 1, 2003-2005)

0

50

100

150

200

250

300

5-6 月，2003

7-9 月 10-12 月 1-3 月 2004 4-6 月 7-9 月 10-12 月 1-3 月 2005 4-6 月 7-9 月

# STI doctors trained # FSW with STI outreach service # patient visits to STI, female

Total doctors trained: 40Average female clients per month: 59Estimated number of FSW in prefecture: 9,800

• There’s room for improvement, but our programe seems to be contributing to limiting onward transmission from injectors who sell sex to clients

• Does that mean we’ve reached our programme goal？

Yes! HIV among sex workers is not rising

Well maybe not. Are we missing an ongoing epidemic in IDU?

Methadone programme introduced

The proportion of female injectors who sell sex is falling

% of female IDU who sell sex, female sex workers who inject, and IDU who are female (Source: Site 1 BSS, 2002-2005)

19

2

41

27

48

35

45

21

2026

0

10

20

30

40

50

60

2002 2003 2004 2005

Female IDU who sell sex FSW who inject drugs % of IDU who are female

…but the proportion of IDU who are women is on the rise

What must we do now?

• Sustain programmes to promote safe sex and condom use, especially for women who inject drugs

• Re-evaluate STI programming, and strengthen if necessary

• Analyse needle exchange and methadone data; urgently strengthen programmes to decrease transmission among injectors