Bias in Self-Reported Condom Use: Association Between Over-Reported Condom Use and Syphilis in a Three-Site Study in China

The impact of past HIV interventions and diagnosis gaps on new HIV acquisitions, transmissions, and HIV-related deaths in Côte d'Ivoire, Mali, and Senegal

OBJECTIVES

To estimate the epidemiological impact of past HIV interventions and the magnitude and contribution of undiagnosed HIV among different risk groups on new HIV acquisitions in Côte d'Ivoire, Mali and Senegal.

DESIGN

HIV transmission dynamic models among the overall population and key populations [female sex workers (FSW), their clients, and MSM].

METHODS

Models were independently parameterized and calibrated for each set of country-specific demographic, behavioural, and epidemiological data. We estimated the fraction of new HIV infections over 2012-2021 averted by condom use and antiretroviral therapy (ART) uptake among key populations and non-key populations, the direct and indirect contribution of specific groups to new infections [transmission population-attributable fraction (tPAF)] over 2012-2021 due to prevention gaps, and the distribution of undiagnosed people with HIV (PWH) by risk group in January 2022 and their tPAF over 2022-2031.

RESULTS

Condom use and ART may have averted 81-88% of new HIV infections over 2012-2021 across countries, mostly due to condom use by key population. The tPAF of all key populations combined over 2012-2021 varied between 27% (Côte d'Ivoire) and 79% (Senegal). Male key populations (clients of FSW and MSM) contributed most to new infections (>60% in Mali and Senegal) owing to their higher HIV prevalence and larger prevention gaps. In 2022, men represented 56% of all PWH with an undiagnosed infection in Côte d'Ivoire (male key populations = 15%), 46% in Mali (male key populations = 23%), and 69% in Senegal (male key populations = 55%). If HIV testing and ART initiation rates remain at current levels, 20% of new HIV infections could be due to undiagnosed key populations living with HIV in Côte d'Ivoire over 2022-2031, 53% in Mali, and 65% in Senegal.

CONCLUSION

Substantial HIV diagnosis gaps remain in Western Africa, especially among male key populations. Addressing these gaps is key to impacting the HIV epidemics in the region and achieving the goal of ending AIDS by 2030.

Stigma in a Collectivistic Culture: Social Network of Female Sex Workers in China

In this egocentric network study, we explored Chinese collectivism in relation to social network characteristics and sex work-related stigma among mid-age female sex workers (FSWs). Respondent-driven sampling was used to recruit 1245 mid-age FSWs from three cities in China. We found that a one standard deviation (SD) increase in FSWs' collectivism was associated with a 0.18 SD decrease in social support (95% CI - 0.32, - 0.04), a 0.20 SD decrease in network effective size (i.e., the diversity of a social network; 95% CI - 0.30, - 0.10), and a 0.21 SD decrease in network betweenness (i.e., the "bridging potential" of egos within their networks; 95% CI - 0.33, - 0.09). Among participants who perceived more sex work stigma, the association between collectivism and FSWs' network betweenness was attenuated. In a collective culture emphasizing group values and honor, belonging to a less interconnected social network may give FSWs a structural advantage to cope with stigma and secure social support.

Improving Underestimation of HIV Prevalence in Surveys Using Time-Location Sampling

We sought to find a method that improves HIV estimates obtained through time-location sampling (TLS) used to recruit most-at-risk populations (MARPs). The calibration on residuals (CARES) method attributes weights to TLS sampled individuals depending on the percentile to which their logistic regression residues belong. Using a real country database, provided by EMIS-2010, with 9591 men who have sex with men (MSM) and an HIV prevalence of 12.1%, we simulated three populations (termed "pseudo-populations") with different levels of HIV. From each pseudo-population, 1000 TLS samples were drawn, and the HIV prevalence estimated by the TLS method and by the CARES method were recorded and compared with the HIV prevalence of the 9591 men. Results showed that the CARES method improves estimates given by the TLS method by getting closer to the real HIV prevalence.

Women at high risk of HIV-infection in Kampala, Uganda, and their candidacy for PrEP

Pre-exposure prophylaxis (PrEP), antiretroviral medication for prevention of HIV-acquisition, is part of biomedical HIV prevention strategies recommended for people at risk of HIV-infection. A decision to take PrEP depends on an assessment of 'being at risk' either by an individual, or healthcare provider. In this paper, we draw on the concept of 'candidacy' to examine the different ways in which women attending a dedicated clinic in Kampala, Uganda, for women at risk of HIV infection (including sex workers), assessed their suitability for PrEP. We conducted in-depth interviews with 30 HIV negative women up to four different times, to gather information on the motives for taking PrEP, and their life history and daily life. All the women described the relevance of PrEP to mitigate their risk of HIV infection. However, there were challenges to adherence because of alcohol use, irregular working hours and a fear of being seen taking pills that others might assume to be HIV treatment. The ways in which the different women used PrEP and interpreted the place of PrEP in their lives were not solely based on their assessment of protecting themselves during sex work. They also used PrEP to guard against infection from their regular partners, and as a tool to allow them to make more money safely, by having sex without a condom with clients. While eligibility to access PrEP was predicated on the women's being in an 'at risk' population group, an incentive to use PrEP was to protect themselves from HIV acquisition from a long-term partner and preserve the 'trust' in their intimate relationship by having condom-less sex. Applying a candidacy lens we highlight the complexity in how women experience and present as being 'at risk' and query the criteria on which categories of risk and PrEP eligibility are determined.

The MOSEXY trial: mobile phone intervention for sexual health in youth-a pragmatic randomised controlled trial to evaluate the effect of a smartphone application on sexual health in youth in Stockholm, Sweden

An estimated 350 million cases of STIs occur globally each year. In Sweden, Chlamydia is the most common STI with approximately 30 000 cases annually, disproportionally affecting youth. National surveys report low condom use among youth. Smartphone coverage is high among this tech-savvy group. In collaboration with youth, we developed an interactive smartphone application comprising games, peer experiences and information snippets to promote condom use.

OBJECTIVES

To evaluate in a randomised controlled trial, the effectiveness of this smartphone application to improve condom use among youth in Stockholm, Sweden.

METHODS

This two-arm, individually randomised controlled trial was implemented through the Youth Health Clinics (YHC) in Stockholm, Sweden. Youth aged 18-23 years, who owned a smartphone and had ≥2 sexual partners during the past 6 months were eligible. The intervention delivered the interactive elements described above over 180 days. The control group received a 'dummy' application. Both groups received standard of care at the YHC. The primary outcome was proportion of consistent (100%) self-reported condom use at 6 months. Secondary outcomes included self-reported number of partners, occurrence of STIs/pregnancy and STI tests during the study period. An intention-to-treat approach was used.

RESULTS

214 and 219 youth were randomised to the intervention and control groups, respectively. Consistent condom use was reported for 32/214 (15.0%) in the intervention group and for 35/219 (16.0%) in the control group (OR 0.9, 95% CI 0.5 to 1.6). No significant differences in secondary outcomes were seen.

CONCLUSION

We were unable to detect an effect of the intervention. Future research should focus on targeting different subgroups within the overall risk group, with tailored mHealth interventions. The potential for such interventions in settings where sexual health services are unavailable should be evaluated.

TRIAL REGISTRATION NUMBER

ISRCTN13212899.

Inequities in consistent condom use among sexually experienced undergraduates in mainland China: implications for planning interventions

BACKGROUND

Since pre-exposure prophylaxis (PrEP) is mainly prescribed to high-risk uninfected individuals, consistent condom use (CCU) continues to be recommended as an inexpensive, feasible, practical and acceptable way to prevent the general population from acquiring and transmitting HIV through sexual intercourse. The objective of this cross-sectional study was to compare the relative importance of various determinants of CCU among sexually experienced undergraduates in mainland China so as to assess and subsequently to suggest ways to eliminate inequities in its use.

METHOD

From September 10, 2018, to January 9, 2019, an anonymous self-administered online questionnaire was voluntarily completed by 12,750 participants distributed across 30 provinces in mainland China (except for Tibet). The present analysis was restricted to 2054 sexually experienced undergraduates. Pearson's chi-square test and Logistic regression models were chosen to analyze the factors associated with CCU.

RESULTS

The overall rate of CCU was 61.3% [95% confidence interval (CI) = 59.2-63.4%]. CCU was inequitably distributed since enabling factors exerted greater effects than predisposing and need variables. Compared with heterosexual men, heterosexual women [adjusted odds ratio (AOR) = 0.78, 95% confidence interval (CI):0.64-0.96)], non-heterosexuals men (AOR = 0.64, 95% CI:0.45-0.92) and women (AOR = 0.68, 95% CI:0.47-0.99) were less prone to using condoms consistently. Those with more resources [i.e., higher levels of self- efficacy for condom use (AOR = 2.86, 95% CI:2.35-3.49) and being knowledgeable of the national AIDS policy (AOR = 1.50, 95% CI:1.23-1.82)], and those with lower need for condoms [i.e., late initiation of sexual activity (AOR = 1.34, 95% CI:1.09-1.64) and single sexual partner (AOR = 1.68,95% CI:1.21-2.33)] were more likely to be consistent condom users.

CONCLUSIONS

In order to increase consistency of condom use and simultaneously reduce the remaining inequities, a comprehensive intervention measure should be taken to target heterosexual women, non-heterosexual men and women, and those with higher need for condoms, improve their condom use self- efficacy and raise their awareness of the national AIDS policy.

A novel nested polymerase chain reaction targeting the testis-specific protein Y-encoded family of genes for high sensitivity of recent semen exposure detection: Comparison with four other assays of semen detection

OBJECTIVES

Because self-report of sexual behaviours is prone to biases, biomarkers of recent semen exposure are increasingly used to assess unprotected sex. We aimed to present a novel nested polymerase chain reaction (PCR) assay targeting testis-specific protein Y-encoded (TSPY) genes and to compare its performance in detecting recent semen exposure with that of four other assays.

METHODS

Forty-five vaginal samples were selected at baseline of a prospective observational demonstration study of early antiretroviral treatment and pre-exposure prophylaxis among female sex workers in Benin. Semen exposure was assessed with: a rapid prostate-specific antigen (PSA) detection assay, a quantitative PCR targeting the sex-determining region (SRY) gene, a standard PCR targeting SRY, a standard PCR targeting TSPY, and a nested PCR targeting TSPY (n-TSPY). Because we had hypothesized that n-TSPY would be the most sensitive of the five assays while remaining specific, and as our results suggested that it was the case, sensitivity and specificity were calculated for each assay in comparison with n-TSPY.

RESULTS

The n-TSPY could detect male DNA at concentration 16 and 64 times lower compared to s-TSPY and s-SRY, respectively. Among the 45 vaginal samples, prevalences of semen exposure according to the different assays varied from 22.2% (95%CI: 11.2%-37.1%) to 70.5% (95%CI: 54.8%-83.2%), with the highest prevalence measured with n-TSPY. The n-TSPY products were of expected size and we observed no false-positive in female DNA controls. The assay that offered the second best performance in detecting semen exposure was the PSA rapid test, with a sensitivity of 61.3% and a specificity of 100% compared to n-TSPY.

CONCLUSIONS

Compared to n-TSPY, all other PCR assays had poor performance to detect semen exposure. The n-TSPY is an accessible assay that may have great utility in assessing semen exposure in studies where many factors are expected to accelerate biomarkers' clearance.

Changes Over Time in HIV Prevalence and Sexual Behaviour Among Young Female Sex-Workers in 14 Sites in Zimbabwe, 2013-2016

Young female sex-workers (FSW) aged 18–24 are at high risk of HIV due to high numbers of sexual partners, difficulty negotiating condom use, increased risk of gender-based violence, and limited access to services. Here we describe changes in sexual behaviours among young FSW across Zimbabwe between 2013 and 2016, and risk factors for prevalent HIV in 2013 and 2016. FSW ≥ 18 years were recruited using respondent-driven sampling in 14 sites across Zimbabwe in 2013 and 2016 as part of the SAPPH-IRe trial. We collected data on socio-demographics and sexual behaviour and offered HIV testing. Statistical analyses were RDS-II weighted. Characteristics of young FSW aged 18–24 were described, stratified by age. Logistic regression was used to assess difference in sexual behaviours by reported HIV status between 2013 and 2016, and to explore associations with prevalent HIV in 2013 and 2016. 656 young FSW were recruited in 2013 and 503 in 2016. Characteristics of young FSW were similar across both surveys. HIV prevalence was similar at both time points (35% vs 36%) and rose steeply with age. Compared to young FSW in 2013, reported condom-less sex with a steady partner and condom-less sex with clients was higher in 2016 among women self-reporting HIV negative status (OR = 6.41; 95%CI: 3.40-12.09; P<0.001) and (OR = 1.69; 95%CI: 1.14-2.51, P = 0.008), respectively, but not among young FSW self-reporting HIV positive status (OR = 2.35; 95%CI: 0.57-9.76; P = 0.236) and (OR = 1.87; 95%CI: 0.74-4.74; P = 0.186). After adjusting for age in 2016, young FSW who had ever been married had increased odds of testing HIV positive (OR = 1.88; 95% CI 1.04–3.39; P = 0.036) compared with those who had never married. Young FSW who completed secondary education or higher were less likely to test HIV positive (OR = 0.41; 95% CI 0.20–0.83; P = 0.012) compared with those with primary education or less. Young FSW remain at very high risk of HIV. Strategies to identify young FSW when they first start selling and refer them into services that address their economic, social and sexual vulnerabilities are critical.

Unintended Pregnancy in Women Living with HIV in Sub-Saharan Africa: A Systematic Review and Meta-analysis

In 2014, about 1.5 million pregnancies occurred among HIV-positive women in low and middle-income countries. To pool magnitude and factors associated with unintended pregnancy in women living with HIV in sub-Saharan Africa, a systematic search of electronic databases was undertaken in November 2016. Pooling the magnitude of unintended pregnancy reported by 14 studies yielded a crude summary prevalence of 55.9%. The magnitude of unwanted pregnancy and mistimed pregnancy in six studies ranged from 14 to 59 and 9 to 47.2%, respectively. Contraceptive failure was an important factor for many unintended pregnancies. The magnitude of unintended pregnancy was significantly higher in HIV-positive women than for HIV-negative women in three out of six studies. The available evidence suggests that there is a high magnitude of unintended pregnancy in this population. Improving effective contraceptive utilization is thus a priority to address unintended pregnancies and to prevent mother to child transmission of HIV. PROSPERO Number: CRD42016051310.

Sexual Behavior With Noncommercial Partners: A Concurrent Partnership Study Among Middle-Aged Female Sex Workers in China

Female sex workers (FSWs) often engage in concurrent partnerships, meaning they have multiple sexual relationships at the same time. The objective of this study was to investigate sexual concurrency and its associations with condom use and syphilitic infections among FSWs over age 35. Respondent-driven sampling was used to recruit 1,245 FSWs in Nanning, Hefei, and Qingdao, China. FSWs were asked to report whether they had concurrent partners in the past six months. Concurrency was defined as engagement in sex with commercial clients and (1) husbands and boyfriends (n = 167); (2) husbands only (n = 301); or (3) boyfriends only (n = 469). FSWs with only commercial clients were used as the comparison group (n = 308). Across all groups, the percentage of FSWs with prevalent and active syphilis ranged from 19.6% to 25.6% and 9.1% to 11.5%, respectively. Condom use was low with noncommercial sexual partners and was more likely to be used when FSWs' boyfriends had other partners. Three components of the theory of planned behavior were significantly associated with consistent condom use. Concurrent relationships may lead to increased transmission of syphilis at the workplace and family levels. Effective interventions should target concurrency with both commercial and noncommercial partners.

Inconsistent Use of Condom in Italian HIV-Serodiscordant Heterosexual Couples as Revealed by the Detection of Y Chromosomal (Yc) DNA in Vaginal Swabs

Introduction:

The prevention of transmission of HIV infection is based on the regular and correct use of condom and studies on transmission rates are generally based on the self-report of condom use.

However, consistent data on different population suggest that this often leads to overreporting possibly due to social desirability. In addition, self-report of condom use does not consider improper use or breakage.

Methods:

Vaginal biomarkers were proposed to detect exposure to semen and among these detection of chromosome Y DNA (Yc) appeared promising in different research settings.

Here, we searched for Yc in vaginal swabs of 33 Italian women, engaged in a regular heterosexual relationship with a HIV serodiscordant partner and reporting a regular use of condom during sexual intercourses.

Results & Discussion:

In 10 (30.3%) women Yc was detected, especially if the infected partner was male and if the couple did not have sons. This is confirmed in Italian heterosexual women and is already demonstrated in other populations: behavioural counselling is not always a valid tool and the self-reported use of condom is not fully reliable.

Conclusion:

Further studies could help in the future to individuate more effective preventive strategies for both HIV and sexually transmitted infections.

Perceived stress and incident sexually transmitted infections in a prospective cohort

PURPOSE

Psychosocial stress has been associated with susceptibility to many infectious pathogens. We evaluated the association between perceived stress and incident sexually transmitted infections (STIs; Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis genital infections) in a prospective study of women. Stress may increase vulnerability to STIs by suppressing immune function and altering the protective vaginal microbiota.

METHODS

Using the 1999 Longitudinal Study of Vaginal Flora (n = 2439), a primarily African American cohort of women, we fitted Cox proportional hazards models to examine the association between perceived stress and incident STIs. We tested bacterial vaginosis (measured by Nugent Score) and sexual behaviors (condom use, number of partners, and partner concurrence) as mediators using VanderWeele's difference method.

RESULTS

Baseline perceived stress was associated with incident STIs both before and after adjusting for confounders (adjusted hazard ratio = 1.015; 95% confidence interval, 1.005-1.026). Nugent score and sexual behaviors significantly mediated 21% and 65% of this adjusted association, respectively, and 78% when included together in the adjusted model.

CONCLUSIONS

This study advances understanding of the relationship between perceived stress and STIs and identifies high-risk sexual behaviors and development of bacterial vaginosis-both known risk factors for STIs-as mechanisms underlying this association.

Can Burt's Theory of Structural Holes be Applied to Study Social Support Among Mid-Age Female Sex Workers? A Multi-Site Egocentric Network Study in China

The epidemic of HIV/AIDS continues to spread among older adults and mid-age female sex workers (FSWs) over 35 years old. We used egocentric network data collected from three study sites in China to examine the applicability of Burt's Theory of Social Holes to study social support among mid-age FSWs. Using respondent-driven sampling, 1245 eligible mid-age FSWs were interviewed. Network structural holes were measured by network constraint and effective size. Three types of social networks were identified: family networks, workplace networks, and non-FSW networks. A larger effective size was significantly associated with a higher level of social support [regression coefficient (β) 5.43-10.59] across the three study samples. In contrast, a greater constraint was significantly associated with a lower level of social support (β -9.33 to -66.76). This study documents the applicability of the Theory of Structural Holes in studying network support among marginalized populations, such as FSWs.

Prevalence and risk factors associated with STIs among women initiating contraceptive implants in Kingston, Jamaica

BACKGROUND

There is limited information on rates of STIs in Jamaica due to syndromic management and limited aetiological surveillance. We examined the prevalence of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV) and characteristics associated with STIs among sexually active women who participated in a randomised trial of a progestin implant initiation in Jamaica (the Sino-Implant Study (SIS)).

METHODS

SIS was a randomised trial conducted in Kingston, Jamaica, from 2012 to 2014 to evaluate whether initiation of the Sino-Implant (II) led to more unprotected sex among women ages 18-44 years. Data collected included self-reported demographic, sexual behaviour information; and vaginal swabs collected at baseline, 1-month and 3-month follow-up visits for a biomarker of recent semen exposure (prostate-specific antigen (PSA)) and for STIs. We examined associations between STIs and PSA, demographics, sexual behaviour and insertion of an implant, with a repeated-measures analysis using generalised estimating equations (SAS Institute, V.9.3).

RESULTS

Remnant vaginal swabs from 254 of 414 study participants were tested for STIs. At baseline, 29% of participants tested for STIs (n=247) had laboratory-confirmed CT, 5% NG, 23% TV and 45% any STI. In a repeated-measures analysis adjusted for study arm (immediate vs delayed implant insertion), those with PSA detected did not have an increased prevalence of any STI (prevalence ratio (PR)=1.04 (95% CI 0.89 to 1.21)), whereas prevalence decreased for each 1-year increase in age (PR=0.98 (95% CI 0.97 to 0.99)). Immediate implant insertion was not associated with increases in any STI in subsequent visits (PR=1.09 (95% CI 0.94 to 1.27)).

CONCLUSIONS

Although the prevalence of laboratory-confirmed STIs was high, the immediate initiation of a contraceptive implant was not associated with higher STI prevalence rates over 3 months.

TRIAL REGISTRATION NUMBER

NCT01684358.

Biomarker validation of self-reported sex among middle-aged female sex workers in China

PURPOSE

The objective of this study was to examine information bias arising from self-reported sexual activity and its association with syphilitic infections among female sex workers (FSWs) aged 35 years and older in China.

METHODS

A questionnaire was administered to 1245 middle-aged FSWs. Respondents self-reported sexual intercourse in the past 48 hours. The prostate-specific antigen test was used to verify self-reported sexual activity. FSWs were considered discordant if they indicated no sexual intercourse in the past 48 hours on the questionnaire and had a positive prostate-specific antigen test. Logistic regression was used to assess the associations between discordance and syphilis.

RESULTS

Three hundred twenty FSWs self-reported no engagement in sexual intercourse in the past 48 hours. One-fourth of respondents (25%) were discordant. Twenty-two percent and 35.8% of discordant FSWs tested positive for active and prevalent syphilis, respectively. After adjusting for confounders, discordant FSWs had 3.8 times the odds of active syphilis (95% confidence interval: 1.52-9.30) and 2.6 times the odds of prevalent syphilis (95% confidence interval: 1.37-5.02), compared with concordant FSWs.

CONCLUSIONS

FSWs who had active or prevalent syphilis were more likely to be discordant. Data collected via self-reported questionnaire may not be a valid tool to assess sexual behavior.

Syphilis among middle-aged female sex workers in China: a three-site cross-sectional study

OBJECTIVES

This study addresses the lack of empirical studies about the epidemic of syphilis among middle-aged female sex workers (FSWs). The objectives of this study were to investigate prevalence of syphilis, and its potential risk factors among middle-aged FSWs in China.

DESIGN

A cross-sectional study with respondent-driven sampling (RDS).

SETTING

A multisite study conducted at three Chinese cites (Nanning, Hefei, and Qingdao) with different levels of sexually transmitted diseases in 2014.

PARTICIPANTS

1245 middle-aged female sex workers who were over 35 years old (about 400 per study site).

MAIN OUTCOME MEASURES

Unprotected commercial sex, and syphilis and HIV infection were biologically tested and measured.

RESULTS

The RDS-adjusted prevalence of active syphilis was 17.3% in Hefei, 9.9% in Qingdao, and 5.4% in Nanning. The RDS-adjusted prevalence of prevalent syphilis was between 6.8% and 33.6% in the three cities. The proportion of unprotected sex in the past 48 h verified by the prostate-specific antigen test (PSA) was between 27.8% and 42.4%. Multiple log-binomial regression analyses indicate that middle-aged FSWs who had 5 or more clients in the past week prior to interviews and engaged in unprotected sex were more likely to be active syphilitic cases. Middle-aged FSWs who had rural residency were less likely to be active syphilitic cases.

CONCLUSIONS

In contrast with previous studies that reported low prevalence of syphilis and high prevalence of protected sex among FSWs in China, both the prevalence of syphilis and unprotected sex were high among middle-aged FSWs. Evidence-based intervention programmes should be developed and evaluated among this vulnerable population in China and other countries with similar settings.

Egocentric Network and Condom Use Among Mid-Age Female Sex Workers in China: A Multilevel Modeling Analysis

The epidemics of sexually transmitted infections (STIs) have spread among older adults in the world, including China. This study addresses the deficiency of studies about the multiple contextual influences on condom use among mid-age female sex workers (FSWs) over 35 years old. A combination of an egocentric network design and multilevel modeling was used to investigate factors of condom use over mid-age FSWs (egos) particular relationships with sexual partners (alters). Of the 1245 mid-age FSWs interviewed, 73% (907) reported having at least one sexual partner who would provide social support to egos. This generated a total of 1300 ego-alter sex ties in egos' support networks. Condoms were consistently used among one-third of sex ties. At the ego level, condoms were more likely to be used consistently if egos received a middle school education or above, had stronger perceived behavioral control for condom use, or consistently used condoms with other sex clients who were not in their support networks. At the alter level, condoms were not consistently used over spousal ties compared to other ties. Condoms were less likely to be used among alters whom ego trusted and provided emotional support. Cross-level factors (egos' attitudes toward condom use and emotional support from alters) documented a significant positive interaction on consistent condom use. Given the low frequency of condom use, future interventions should focus on mid-age FSWs and their partners within and beyond their support networks.