A randomized controlled trial of an HIV prevention intervention for street-based female sex workers in Yerevan, Armenia: preliminary evidence of efficacy. A randomized controlled trial to evaluate the relative efficacy of adding voluntary counseling and testing (VCT) to information dissemination in reducing HIV-related risk behaviors among Hong Kong male cross-border truck drivers. Randomised controlled trial of alternative male and female condom promotion strategies targeting sex workers in Madagascar. Impact and process evaluation of integrated community and clinic-based HIV-1 control: a cluster-randomised trial in eastern Zimbabwe. Short-term effect of a cultural adaptation of voluntary counseling and testing among female sex workers in China: a quasi-experimental trial. Acceptability of a microenterprise intervention among female sex workers in Chennai, India. A randomized controlled trial to promote long-term contraceptive use among HIV-serodiscordant and concordant positive couples in Zambia. Constraints faced by sex workers in use of female and male condoms for safer sex in urban zimbabwe. Promoting HIV testing and condom use among Filipina commercial sex workers: findings from a quasi-experimental intervention study. Efficacy of a brief behavioral intervention to promote condom use among female sex workers in Tijuana and Ciudad Juarez, Mexico. Empowering sex workers in India to reduce vulnerability to HIV and sexually transmitted diseases. Community-level HIV intervention in 5 cities: final outcome data from the CDC AIDS Community Demonstration Projects. Effectiveness of an intervention to reduce HIV transmission risks in HIV-positive people.
This study evaluated the efficacy of an HIV intervention among female sex workers (FSWs) randomized to an intervention or wait-list control. FSWs (N = 120) completed baseline, 3- and 6-month assessments. A health educator implemented 2-hour intervention emphasized gender-empowerment, self-efficacy to persuade clients to use condoms, condom application skills, and eroticizing safer sex. Over the 6-month follow-up, FSWs in the intervention reported more consistent condom use with clients (P = .004) and were more likely to apply condoms on clients (P = .0001). Intervention effects were observed for other psychosocial mediators of safer sex. Brief, gender and culturally congruent interventions can enhance HIV-preventive behaviors among FSWs. Mobile populations are vulnerable to contracting HIV. The present study aims to evaluate the relative efficacy of the voluntary counseling and testing plus information dissemination (VCT-ID) approach versus the information dissemination (ID) approach for promoting HIV preventive behaviors in a mobile population, cross-border truck drivers. A total of 301 adult male cross-border truck drivers who self-reported having had sex with female sex workers (FSW) or non-regular sex partners (NRPs) in mainland China in the last 12 months were recruited and randomized into the VCT-ID intervention group (Group I) or ID control group (Group C). Anonymous structured questionnaires, administered through a computer-assisted method, were used to collect data. At the follow-up survey (about 8-9 weeks since the baseline survey), Group I participants, as compared to Group C participants, were more likely to be consistent condom users when having sex with FSW (85.5% versus 68.5%, p<0.05) and with NRP (54.8% versus 36.4%, p<0.1), more knowledgeable about HIV, and were less likely to have contracted sexually transmitted diseases (STD) in the last two months. The VCT-ID approach is shown to be more efficacious than the ID approach in promoting safer sex and HIV-related knowledge among local cross-border truck drivers. Feasibility of providing voluntary counseling and testing (VCT) services at locations which are convenient to the target population is demonstrated. It also shows that VCT services can be used as a means of HIV prevention. The findings of this study resulted in up-scaled VCT services for the local target population. To assess whether individual clinic-based counselling as a supplement to peer education for male and female condom promotion leads to greater use of protection and lower STI prevalence among sex workers in Madagascar already exposed to intensive male condom promotion.
                In two public dispensaries in Madagascar, a total of 901 sex workers were randomly allocated between two alternative male and female condom promotion
                peer education only, or peer education supplemented with individual clinic-based counselling. Participants were followed for 12 months. Every 2 months they made clinic visits, where they were interviewed on condom use. Peer educators counselled all participants on condom use as they accompanied their assigned participants to study visits. Participants assigned to receive the supplemental intervention were counselled by a trained clinician following study interviews. Participants were tested and treated for chlamydia, gonorrhoea and trichomoniasis every 6 months. We used logistic regression to assess whether the more intensive intervention was associated with reduced STI prevalence. Use of protection with clients and non-paying partners was assessed by study arm, site, and visit.
                There was no statistically significant association between study arm and aggregated STI prevalence. No substantial differences in levels of reported protection were noted between study groups.
                This study found little evidence for gains from more thorough clinical counselling on male and female condom use. These findings suggest that less clinically intensive interventions such as peer education could be suitable for male and female condom promotion in populations already exposed to barrier method promotion. HIV-1 control in sub-Saharan Africa requires cost-effective and sustainable programmes that promote behaviour change and reduce cofactor sexually transmitted infections (STIs) at the population and individual levels.
                We measured the feasibility of community-based peer education, free condom distribution, income-generating projects, and clinic-based STI treatment and counselling services and evaluated their impact on the incidence of HIV-1 measured over a 3-y period in a cluster-randomised controlled trial in eastern Zimbabwe. Analysis of primary outcomes was on an intention-to-treat basis. The income-generating projects proved impossible to implement in the prevailing economic climate. Despite greater programme activity and knowledge in the intervention communities, the incidence rate ratio of HIV-1 was 1.27 (95% confidence interval [CI] 0.92-1.75) compared to the control communities. No evidence was found for reduced incidence of self-reported STI symptoms or high-risk sexual behaviour in the intervention communities. Males who attended programme meetings had lower HIV-1 incidence (incidence rate ratio 0.48, 95% CI 0.24-0.98), and fewer men who attended programme meetings reported unprotected sex with casual partners (odds ratio 0.45, 95% CI 0.28-0.75). More male STI patients in the intervention communities reported cessation of symptoms (odds ratio 2.49, 95% CI 1.21-5.12).
                Integrated peer education, condom distribution, and syndromic STI management did not reduce population-level HIV-1 incidence in a declining epidemic, despite reducing HIV-1 incidence in the immediate male target group. Our results highlight the need to assess the community-level impact of interventions that are effective amongst targeted population sub-groups. This study evaluates the efficacy of cultural adaptation of a voluntary counseling and testing (VCT) intervention, in increasing condom use and decreasing rates of sexually transmitted diseases (STDs) among a group of female sex workers (FSWs) in Guangxi, China. This intervention is modeled after the "state-of-the-science" VCT program that was developed and evaluated by the Center for Disease Control and Prevention's Project RESPECT. Four hundred FSWs were assigned to either an intervention group receiving the VCT intervention or a control group receiving standard of care STD testing and treatment. Data were collected at baseline and 6 months postintervention. Outcome measures included HIV/STD related knowledge and perceptions, condom use, and history of STDs. Five common STDs were screened and tested through clinical examination and laboratory testing to serve as biomarkers. After controlling for potential confounders and baseline differences, the VCT intervention group was significantly higher than the control group in HIV/STD related knowledge (p < .0001) and consistent condom use with clients (odds ration [OR] = 2.23; 95% confidence interval [CI] = 1.26-3.96) at 6 months follow-up. In addition, the intervention group had a significantly lower infection rate of STDs than the control group at follow-up (OR = 0.44; 95% CI = 0.24-0.80). This quasi-experimental trial provides evidence that the brief VCT intervention, through appropriate cultural adaptation, can be efficacious in increasing condom use and reducing STD infection rate among FSWs in China. Female sex workers have been central in India's HIV epidemic since it was first diagnosed among them in 1989. Female sex workers' risk of HIV is primarily economically motivated. The Pi pilot study examined the feasibility and association of a microenterprise intervention, the tailoring of canvas bags, on sexual risk behaviors among female sex workers (N = 100) in Chennai. Women were randomized to an intervention or control arm. Between-group comparisons at baseline and at six-month follow-up were performed. Multivariate linear regression with bootstrapping was conducted to estimate the intervention effect. At baseline, women were a median of 35 years old, 61% were married and they had an average of two children. Intervention participants reported a significantly lower number of sex partners and significant increases in income at the 6-month follow-up compared to control participants. In a multivariate model, intervention participants had a significantly lower number of paying clients per month at follow-up compared to control participants. By graduation, 75% of intervention arm participants had made at least one sellable canvas bag and 6 months after the study's end, 60% have continued involvement in bag production. The pilot study demonstrated that microenterprise interventions are successful in both providing FSWs with licit income opportunities and was associated with reductions in HIV risk behaviors. Countries facing high HIV prevalence often also experience high levels of fertility and low contraceptive use, suggesting high levels of unmet need for contraceptive services. In particular, the unique needs of couples with one or both partners HIV positive are largely missing from many current family planning efforts, which focus on the prevention of pregnancies in the absence of reduction of the risk of HIV and other sexually transmitted infections (STIs).
                This article presents an examination of contraceptive method uptake among a cohort of HIV serodiscordant and concordant positive study participants in Zambia.
                Baseline contraceptive use was low; however, exposure to a video-based intervention that provided information on contraceptive methods and modeled desirable future planning behaviors dramatically increased the uptake of modern contraceptive methods.
                Including information on family planning in voluntary counseling and testing (VCT) services in addition to tailoring the delivery of family planning information to meet the needs and concerns of HIV-positive women or those with HIV-positive partners is an essential step in the delivery of services and prevention efforts to reduce the transmission of HIV. Family planning and HIV prevention programs should integrate counseling on dual method use, combining condoms for HIV/STI prevention with a long-acting contraceptive for added protection against unplanned pregnancy. We investigated whether female condoms are acceptable to sex workers in Harare and whether improved access to male and female condoms increases the proportion of protected sex episodes with clients and boyfriends. Sex workers were randomly placed in groups to receive either male and female condoms (group A, n = 99) or male condoms only (group B, n = 50) and were followed prospectively for about 3 months each. We found a considerable burden of human immunodeficiency virus (HIV) and sexually transmitted infections (STIs) in our cohort at enrollment (86% tested HIV positive and 34% had at least one STI). Consistent male condom use with clients increased from 0% to 52% in group A and from 0% to 82% in group B between enrollment and first follow-up 2 weeks later and remained high throughout the study. Few women in group A reported using female condoms with clients consistently (3%-9%), and use of either condom was less common with boyfriends than with clients throughout the study (8%-39% for different study groups, visits, and types of condom). Unprotected sex still took place, as evidenced by an STI incidence of 16 episodes per 100 woman-months of follow-up. Our questionnaire data indicated high self-reported acceptability of female condoms, but focus group discussions revealed that a main obstacle to female condom use was client distrust of unfamiliar methods. This study shows that a simple intervention of improving access to condoms can lead to more protected sex episodes between sex workers and clients. However, more work is needed to help sex workers achieve safer sex in noncommercial relationships. This study examines the effects of a multi-level social action-based theory (SABT) intervention to increase HIV testing and consistent condom use among female commercial sex workers (FCSWs). Respondents in four socio-demographically similar Philippine cities received an SABT intervention based on: (1) peer influence; (2) manager training; (3) combined peer/manager influence; or (4) usual care (control condition). HIV testing increased 86% from baseline (N = 980) to follow-up (N = 903), and was significantly associated with higher HIV/AIDS knowledge, lower probability of contracting HIV and increased condom use. After adjusting for socio-demographic, HIV knowledge and perceived control variables, FCSWs in the manager training and combined peer/manager conditions were significantly more likely to engage in consistent condom use. Mediational analyses revealed higher HIV/AIDS risk perceptions and a supportive work environment related to increased condom use. These findings support a growing body of research suggesting the need for multi-level sexual risk reduction interventions among FCSWs. We examined the efficacy of a brief behavioral intervention to promote condom use among female sex workers in Tijuana and Ciudad Juarez, Mexico.
                We randomized 924 female sex workers 18 years or older without known HIV infection living in Tijuana and Ciudad Juarez who had recently had unprotected sex with clients to a 30-minute behavioral intervention or a didactic control condition. At baseline and 6 months, women underwent interviews and testing for HIV, syphilis, gonorrhea, and chlamydia.
                We observed a 40% decline in cumulative sexually transmitted illness incidence (P = .049) in the intervention group. Incidence density for the intervention versus control groups was 13.8 versus 24.92 per 100 person-years for sexually transmitted illnesses combined (P = .034) and 0 versus 2.01 per 100 person-years for HIV (P < .001). There were concomitant increases in the number and percentage of protected sex acts and decreases in the number of unprotected sex acts with clients (P < .05).
                This brief behavioral intervention shows promise in reducing HIV and sexually transmitted illness risk behaviors among female sex workers and may be transferable to other resource-constrained settings. The Sonagachi Project was initiated in Kolkata, India in 1992 as a STD/HIV intervention for sex workers. The project evolved to adopt strategies common to women's empowerment programs globally (i.e., community mobilization, rights-based framing, advocacy, micro-finance) to address common factors that support effective, evidence-based HIV/STD prevention. The Sonagachi model is now a broadly diffused evidence-based empowerment program. We previously demonstrated significant condom use increases among female sex workers in a 16 month replication trial of the Sonagachi empowerment intervention (n=110) compared to a control community (n=106) receiving standard care of STD clinic, condom promotion, and peer education in two randomly assigned rural towns in West Bengal, India (Basu et al., 2004). This article examines the intervention's impacts on 21 measured variables reflecting five common factors of effective HIV/STD prevention programs to estimate the impact of empowerment strategies on HIV/STD prevention program goals. The intervention which was conducted in 2000-2001 significantly: 1) improved knowledge of STDs and condom protection from STD and HIV, and maintained STD/HIV risk perceptions despite treatment; 2) provided a frame to motivate change based on reframing sex work as valid work, increasing disclosure of profession, and instilling a hopeful future orientation reflected in desire for more education or training; 3) improved skills in sexual and workplace negotiations reflected in increased refusal, condom decision-making, and ability to change work contract, but not ability to take leave; 4) built social support by increasing social interactions outside work, social function participation, and helping other sex workers; and 5) addressed environmental barriers of economic vulnerabilities by increasing savings and alternative income, but not working in other locations, nor reduced loan taking, and did not increase voting to build social capital. This study's results demonstrate that, compared to narrowcast clinical and prevention services alone, empowerment strategies can significantly impact a broader range of factors to reduce vulnerability to HIV/STDs. This study evaluated a theory-based community-level intervention to promote progress toward consistent condom and bleach use among selected populations at increased risk for HIV infection in 5 US cities.
                Role-model stories were distributed, along with condoms and bleach, by community members who encouraged behavior change among injection drug users, their female sex partners, sex workers, non-gay-identified men who have sex with men, high-risk youth, and residents in areas with high sexually transmitted disease rates. Over a 3-year period, cross-sectional interviews (n = 15,205) were conducted in 10 intervention and comparison community pairs. Outcomes were measured on a stage-of-change scale. Observed condom carrying and intervention exposure were also measured.
                At the community level, movement toward consistent condom use with main (P < .05) and nonmain (P < .05) partners, as well as increased condom carrying (P < .0001), was greater in intervention than in comparison communities. At the individual level, respondents recently exposed to the intervention were more likely to carry condoms and to have higher stage-of-change scores for condom and bleach use.
                The intervention led to significant communitywide progress toward consistent HIV risk reduction. As many as one in three HIV-positive people continue unprotected sexual practices after learning that they are HIV infected. This article reports the outcomes of a theory-based intervention to reduce risk of HIV transmission for people living with HIV infection.
                Men (n=233) and women (n=99) living with HIV-AIDS were randomly assigned to receive either (1) a five-session group intervention focused on strategies for practicing safer sexual behavior, or (2) a five-session, contact-matched, health-maintenance support group (standard-of-care comparison). Participants were followed for 6 months post-intervention.
                The intervention to reduce risk of HIV transmission resulted in significantly less unprotected intercourse and greater condom use at follow-up. Transmission-risk behaviors with non-HIV-positive sexual partners and estimated HIV transmission rates over a 1-year horizon were also significantly lower for the behavioral risk-reduction intervention group.
                This study is among the first to demonstrate successful HIV-transmission risk reduction resulting from a behavioral intervention tailored for HIV-positive men and women.
Available evidence nevertheless suggests that compared with standard care or no intervention, behavioral interventions are effective in reducing HIV and the incidence of STIs amongst female sex workers (FSWs). Given the benefits of social cognitive theory and the promotion of condom use in reducing HIV/STI and the public health need to control transmission amongst FSWs, there is a clear finding in favour of behavioral interventions. However, it should be recognized that there is a lack of information about most other outcomes and target populations, and that all of the trials were conducted in low- and middle-income countries.