HIV-1 infection among lower class commercial sex workers in Chiang Mai, Thailand

The Prevalence of HIV Infection in Minority Indigenous Populations of the South-East Asia and Western Pacific Regions: A Systematic Review and Meta-analysis

A random effects meta-analysis was used to estimate the pooled prevalence of HIV infection within minority indigenous populations of the South-East Asia (SEAR) and Western Pacific Regions (WPR). Sub-group analyses were conducted, and the sources of heterogeneity explored through meta-regression. The majority of studies were undertaken in high HIV risk subpopulations. There was a paucity of data for many countries with data from China representing 70% of the comparative studies. Within minority indigenous populations the pooled prevalence of HIV infection was 13.7% (95% CI 8.9, 19) and 8.4% (95% CI 6.3, 10.7) among other populations. The prevalence differential between populations was significant in the WPR (adjusted odds ratio 1.1, 95% CI 1.0, 1.2). Across both regions, in contrast to other populations, minority indigenous did not experience any significant reduction in HIV prevalence over the years of data collection. There was large heterogeneity in the prevalence of HIV across studies.

Intimate Relationships and HIV Infection Risks Among Shan Female Sex Workers From Myanmar in Chiang Mai, Thailand: A Qualitative Study

This study aimed to investigate HIV risks among female sex workers (FSWs) who were from the Shan ethnic group, and how they relate to complex relationships with inconsistent condom use. The study was conducted using in-depth interviews with 17 Shan FSWs (aged 18-45 years old) in Chiang Mai. Intimate relationships between participants and regular clients/steady partners were found to facilitate inconsistent condom use. Participating Shan FSWs sustained intimacy with regular clients not only for economic ends but also for emotional support. Gender norms and male power dominated condom use decision making. Some participants lacked proper HIV preventive knowledge regarding condom breakage and HIV risks. Effective intervention and proper HIV preventive practices should address these intimate contexts. Capacity building among women would assist FSWs to make choices that protect them from HIV/STDs infections. Couples-based HIV interventions addressing emotional intimacy is an urgent need for HIV communication and service delivery in Thailand.

Prevalence and factors associated with hepatitis B and D virus infections among migrant sex workers in Chiangmai, Thailand: A cross-sectional study in 2019

OBJECTIVES

To determine the prevalence of hepatitis B surface antigen (HBsAg) and antibody to hepatitis delta virus (anti-HDV) and associated factors among migrant sex workers in Chiangmai, Thailand.

METHODS

This cross-sectional study was conducted at various sexual entertainment venues in Chiangmai, Thailand, in 2019. Consenting participants were interviewed using a questionnaire, and plasma was tested for hepatitis B virus (HBV) markers (DiaSorin, Italy) and anti-HDV antibody (DIA.PRO Diagnostic Bioprobes, Italy), if HBsAg-positive. Associations between HBsAg positivity or HDV antibody and potential factors were examined using univariable and multivariable logistic regression analysis.

RESULTS

A total of 396 migrant sex workers, half of them female, were recruited between February and September 2019. Their median age was 25 years (interquartile range 22-30 years) and 95% were Burmese. Overall, HBsAg prevalence was 11.4%; 8.1% in females and 14.7% in males (Chi-square, p = 0.040). One-third were still susceptible to HBV. No HBsAg-positive participants had anti-HDV antibodies. HBsAg positivity was associated with being male (adjusted odds ratio (aOR) 3.01, 95% confidence interval (CI) 1.25-7.68, p = 0.014), having attended school (aOR 4.50, 95% CI 1.26-15.98, p = 0.020), being separated/divorced/widowed (aOR 5.77, 95% CI 1.48-22.52, p = 0.012), and having unprotected sex (aOR 3.38, 95% CI 1.31-8.71, p = 0.012).

CONCLUSIONS

In this young population, higher HBsAg prevalence in males may be related to sexual transmission, indicating the need for HBV screening programs linked with HBV prevention and care.

Moral Panic and the Construction of National Order

This article examines some of the major concepts used to model the Thai AIDS epidemic and to direct interventions, in particular, the concepts of discrete risk groups and of the sequential spread of HIV from group to group in a wave-like fashion which, although they have been largely discredited in the international AIDS literature, retain a high degree of currency in Thailand. I argue that Thailand’s HIV/AIDS epidemic had the effect of bringing sexual practices from the private sphere into the public arena, where the concept of risk group rendered visible the social body of modern Thailand as a hierarchy of risk, with specific groups attributed behaviours necessitating control. This notion found enduring favour in Thailand because it reinforced existing social prejudices about members of groups such as the male underclass, prostitutes and injecting drug users, and legitimated the claims of government and non-government organizations for the monitoring and control of these groups. There has been a high level of consensus over this strategy, and a lack of competing discourses. Thus Thai AIDS discourse has not only failed to transcend state and middle-class notions of morality and normativity, but it has also failed to come to terms with Thailand’s changing sexual cultures.

Analysis of HIV Correlated Factors in Chinese and Vietnamese Female Sex Workers in Hekou, Yunnan Province, a Chinese Border Region

Objectives

To assess the prevalence and correlated factors of HIV-1 among Chinese and Vietnamese female sex workers (FSW) in the border county of Hekou, Yunnan province, China.

Methods

A cross-sectional survey was conducted collecting information on demographics, sexual behavior, medical history, and drug use. Blood samples were obtained to test for HIV/STIs. Multivariate logistic regression model was used to examine associations between factors and HIV-1 infection.

Results

Of 345 FSWs who participated in this study, 112 (32.5%) were Chinese and 233 (67.5) were Vietnamese. Vietnamese FSWs were significantly more likely to be HIV-1 positive (7.7%) compared with Chinese FSWs (0.9%) (p = 0.009). In multivariate analysis, sexual debut at age≤16 (OR 3.8: 95% CI: 1.4, 10.6), last client’s payment <150 RMB ($22 USD) (OR: 5.2, 95% CI; 1.7, 16.6), and HSV-2 (OR: 12.3; 95% CI: 1.6, 94.8) were significant for HIV-1 infection.

Conclusions

Differences in HIV prevalence in Vietnamese and Chinese FSWs may be indicative of differential risk. It is important to characterize the nature of trans-border transmission in order to gain a better understanding of the potential impact on the international HIV epidemic. Understanding the correlated factors for HIV in Vietnamese and Chinese FSWs is important for designing interventions for this vulnerable population.

Biomedical HIV prevention research and epidemic control in Thailand: two sides of the same coin

For a country with a moderate adult HIV prevalence of just over 1% in 2012, Thailand is widely perceived as having made some extraordinary contributions to the global management of the HIV/AIDS pandemic. It has been promoted as a model of effective HIV control and applauded for its leadership in providing access to antiretroviral treatment. Thailand has also received international recognition for its contribution to biomedical HIV prevention research, which is generally perceived as exceptional. In this paper, Thailand's global role model function as an example of effective HIV/AIDS control and high-quality biomedical HIV prevention research is re-evaluated against the background of currently available data and more recent insights. The results indicate that Thailand's initial response in raising the level of the political significance of HIV/AIDS was indeed extraordinary, which probably prevented a much larger epidemic from occurring. However, this response transpired in unusual extraconstitutional circumstances and its effectiveness declined once the country returned to political normalcy. Available data confirm the country's more than exceptional contribution to biomedical HIV prevention research. Thailand has made a huge contribution to the global management and control of the HIV/AIDS pandemic.

Analysis of duration of risk behaviour for key populations: a literature review

Background

The objective of this paper is to review literature in order to calculate regional estimates of the average duration of time individuals maintain a specific high-risk behaviour.

Methods

The review targeted the key populations of female sex workers (FSW), male clients of female sex workers (MCFSW), people who inject drugs (injecting drug users (IDU)) and high-risk men who have sex with men (MSM). To be included in the review the study had to provide information on (1) the time a person spent at risk until death or cessation of the risk behaviour, (2) the percentage of the sample who initiated the risk behaviour in less than a year or (3) the mean or median duration of the behaviour from a representative sample.

Results

49 papers were found for the FSW population describing the period of time FSW stay in sex work to be between 2.9 years (Asia) and 12 years (Latin America). Eight papers were found for MCFSW showing the duration of the risk behaviour in this category varying from 4.6 years in Africa to 32 years in Asia. 86 papers were reviewed for the population of IDU showing that the average time a person injects illegal drugs varies from 5.6 years (Africa) to 21 years (South America). No information was found for duration of high-risk behaviour among MSM; instead, the definitions found in the literature for high- and low-risk behaviour among MSM were described.

Conclusions

There is high variability of estimates of duration of high-risk behaviours at regional level. More research is needed to inform models and prevention programmes on the average duration of time individuals maintain a specific high-risk behaviour.

Commercial sex and HIV transmission in mature epidemics: a study of five African countries

The study compares the association between using the services of commercial sex workers and male HIV seroprevalence in five African countries: Ghana, Kenya, Lesotho, Malawi and Rwanda. The HIV seroprevalence among men who 'ever paid for sex' was compared with controls who 'never paid for sex'. Results were based on 12,929 eligible men, aged 15-59 years, interviewed in Demographic and Health Surveys. The odds ratio of HIV seroprevalence associated with ever paying for sex was 1.89 (95% confidence interval = 1.57-2.28), with only minor differences by country. The results were stable in multivariate analysis after controlling for available potential cofactors (data on non-sexual routes of transmission were not available). Given the relatively small proportion of men involved, the risk attributable to 'ever paying for sex' remained low: 7.1% in univariate analysis and 4.4% after adjustment, and it varied among countries (range 1.3-9.4%). These results match previous observations that commercial sex seems to play a minor role in the spread of HIV in mature epidemics.

Sexually transmitted infection service use and risk factors for HIV infection among female sex workers in Georgetown, Guyana

OBJECTIVES

To identify risk factors for HIV and sexually transmitted infection (STI) service use patterns among female sex workers in Georgetown, Guyana.

DESIGN

A cross-sectional study was conducted among 299 female commercial sex workers.

METHODS

HIV prevalence was assessed using an oral fluid test, and sociodemographic and behavioral data by interview administered by sex workers and women's group members.

RESULTS

HIV prevalence was 30.6% [95% confidence interval (CI) 24.9-36.3]. Multivariate logistic regression found a significant association between HIV infection and having a vaginal ulcer in the last 12 months [odds ratio (OR) 4.0, CI 1.4-12.0]. Having had a vaginal ulcer was associated with use of cocaine. Multivariate logistic regression on STI service use variables found significant associations between HIV infection and getting condoms from public sector STI services (OR 3.1, CI 1.6-5.8), not going back for HIV test results (OR 3.4, CI 1.1-10.1), and last getting tested for HIV more than 6 months ago (OR 2.8, CI 1.3-6.2).

CONCLUSIONS

An active program of screening and treatment of ulcerative STIs should be combined with substance abuse services for sex workers (SW). Condom promotion services are reaching SW at high risk, but HIV stigma may prevent SW at high risk from accessing HIV test results.

'It's in the nature of men': women's perception of risk for HIV/AIDS in Chiang Mai, Thailand

The paper examines the context of women's risk for HIV by assessing men's and women's sexual behaviour, attitudes towards sex work, and perception of risk for HIV in the city of Chiang Mai, Thailand. The findings are based on data collected in the mid-1990s, at the height of the epidemic. A range of significant issues were highlighted by the men and women who participated in this study. First, some men continued to have unsafe sex with sex workers. Second, fear of HIV motivated men to seek out friends and acquaintances instead of sex workers for sexual encounters because they were considered 'safe' from infection. Third, women in this study were largely unaware of this expansion of the sexual network beyond the sex work itself. Lastly, women's sexuality was largely unrecognized in public health responses, or by the male and female participants, leaving them at risk for HIV.

The relationship between HIV/Sexually Transmitted Infection risk and alcohol use during commercial sex episodes: results from the study of female commercial sex workers in the Philippines

The HIV/Sexually Transmitted Infection (STI) risk associated with alcohol use between female commercial sex workers (FCSWs) and their customers has been understudied. We examined this relationship for 1,114 FCSWs aged 15-54 with data collected during the baseline study period (1994 to 1998) in four southern provinces of the Philippines. Two alcohol-related risk situations during commercial sex episodes were examined: prior alcohol use by an FCSW and perceived intoxication in a customer. The influence of sociodemographic variables on sexual risk behaviors was also studied. Multiple sexual risk behaviors were observed with more frequency for FCSWs if alcohol was used before commercial sex or if the episode involved a customer perceived to be intoxicated. Forty-two percent of FCSWs who had sex with an intoxicated customer were STI positive, significantly more than FCSWs who did not have sex with an intoxicated customer (28%, p < .01). Similar significant differences were found for FCSWs who did not consume alcohol before having sex and were STI positive (29%) versus FCSW who did consume alcohol before sex and were STI positive (33%, p < .01). Our analyses reinforce accumulating evidence in the field that sexual risk reduction interventions need to go beyond the behaviors of individual FCSWs to meet the layering of risks such as observed in this study. Multilevel strategies targeting customer substance use and other situational and structural factors have proven to be pivotal mediators in our other research with this population. These experiences and the limitations of this study are discussed.

Factors associated with HIV testing, condom use, and sexually transmitted infections among female sex workers in Nha Trang, Vietnam

This study examined predictors of HIV testing, successful condom negotiation with clients, and self-reported sexually transmitted infections (STIs) among Vietnamese female sex workers (FSW). Data were collected by using face-to-face interviews from a community sample of 610 FSW from Nha Trang city during October-December, 2000. Having had an HIV test was associated with having spent time in a rehabilitation center. Consistently successful negotiation of condom use occurred most among FSW who had few clients, understood how HIV was not transmitted, and had not reported ever having any symptoms of STIs. Migration to Nha Trang for sex work was a risk factor for an STI diagnosis; successful negotiation of condom use had a protective effect. Our results suggest the need for voluntary HIV counseling and testing, further promotion of condom use among FSW populations, and better use of rehabilitation sites to promote HIV prevention.

Traditions in transition: young people's risk for HIV in Chiang Mai, Thailand

Thailand is in the midst of a social and sexual transition that is affecting gender roles, sexual behavior, and, hence, risk for HIV. The continuation of past traditions, such as men having sex with commercial sex workers, coupled with an increasing acceptance of noncommercial premarital sex among young people, is fueling the AIDS epidemic. To examine young people's potential risk for HIV, the author investigated their perspectives on sexual behavior and sexual networking, the continued acceptance of premarital sex with commercial sex workers, and perception of risk for HIV in Chiang Mai. This study suggests that a changing social environment and the response to the AIDS epidemic have resulted in new patterns of sexual behavior that might trigger the dissemination of HIV into a broader network.

Intravenous drug use among street-based sex workers: a high-risk behavior for HIV transmission

BACKGROUND

HIV prevalence among sex workers in Ho Chi Minh City has increased rapidly, from 6.5% in 1999 to 18.1% in 2000. This study examined whether injecting drug use among street-based sex workers (SSWs) in Ho Chi Minh City is a high-risk factor for HIV infection.

GOAL

The goal of this study was to determine the correlates and prevalence of intravenous drug users among SSWs in Ho Chi Minh City.

STUDY DESIGN

A cross-sectional study was conducted among SSWs in Ho Chi Minh City during December 2000. The SSWs were interviewed and tested for HIV-1.

RESULTS

HIV-1 seroprevalence was 16.3%. Regression analysis indicated that injecting drugs and being younger than 25 years of age were independently associated with HIV seropositivity.

CONCLUSION

Young SSWs who inject drugs are at the greatest risk of contracting HIV and acting as a bridge for HIV to the sexually active population.

The social organization of commercial sex work in Moscow, Russia

BACKGROUND

Increased poverty, unemployment, and migration place the Russian population at high risk for sexually transmitted infections (STIs). A qualitative study was undertaken to clarify the organization of sex work and describe the likely contributions of different types of sex work to disease transmission.

GOAL

The goal of the study was to describe the social-organizational patterns of sex work in Moscow, Russia.

STUDY DESIGN

Four qualitative data collection methods were used: semistructured telephone interviews, semistructured face-to-face individual and group interviews with key informants, systematic and unobtrusive naturalistic observations, and geomapping.

RESULTS

Intermittent, truck stop, and railway station sex workers may be the most important groups in the dissemination of STIs. Sex work is widely disseminated throughout the city. Identifiable positions in the social organization of street sex work include pimps, assistant female pimps, guards, drivers, "indicators," the sex workers themselves, and recruitment "pluckers."

CONCLUSION

The Moscow sex market may be an adjustive response of the social system to the economic pressures in Russia. Sex work in Moscow has great potential for disseminating STIs throughout Russia and beyond. Understanding of these issues may enhance the impact of STI prevention programs.

Lifetime correlates associated with amphetamine use among northern Thai men attending STD and HIV anonymous test sites

AIMS

To investigate the demographic, sexual, and other substance use risk correlates of amphetamine use among men in northern Thailand prior to the current epidemic of amphetamine use in the Kingdom.

DESIGN

Cross-sectional quantitative behavioral questionnaires.

SETTING

Thai Ministry of Health STD and HIV Anonymous Test Sites in the upper northern provinces of Chiang Mai and Lamphun.

PARTICIPANTS

Adult Thai men recruited at clinics for enrollment in an HIV seroincidence cohort study (The Thai HIVNET). All men were HIV negative at enrollment, and had at least one self-reported sexual risk for HIV infection (a recent STD, use of sex workers, multiple sexual partners, low or absent condom use, sex with men).

MEASUREMENTS

Participants answered a structured questionnaire.

FINDINGS

Lifetime history of amphetamine use was reported by 133/914 men, 14.5%. Older age was protective for use (odds ratio (OR) 0.5) and use was associated with use of other substances; heroin (OR 7.1), thinner (OR 6.2), opium (OR 5.9), and marijuana (OR 5.7). Several STDs were associated with amphetamine use: gonorrhea (OR 2.3) and genital warts (OR 2.4), and any STD (OR 1.9). In multivariate analysis, use of heroin (OR 3.1), soft drugs (OR 4.9), and a history of gonorrhea (OR 2.0) were independently associated with amphetamine use in northern Thai men.

CONCLUSIONS

Associations between young age, gonorrhea, other substance use and amphetamines indicate that prevention measures could occur at STD clinics and be incorporated into school programs when individuals are entering adolescence.

Acceptance of HIV testing and counseling among unmarried young adults in Northern Thailand

A cluster randomized trial was used to assess the effect of an active group intervention in promoting utilization of voluntary HIV testing and counseling (HIV-TC). Villagers from 40 clusters were sampled to represent the premarital age population and assigned into two groups, intervention and comparison. The intervention was designed to enhance risk perception and increase knowledge about HIV testing. Interviews were performed before and after the intervention. At baseline, 23% of 398 participants had been tested for HIV at least once and 90% reported testing positive. Most participants perceived that they had no chance of being infected with HIV. Among the intervention group, 71% participated in the intervention activities. The risk ratio of HIV-TC acceptance among the intervention group was 2.92, but the risk difference was only 8.11%. Factors associated with HIV-TC acceptance were ever having had a sexually transmitted disease, being previously married, intention to get tested, and having partici pated in AIDS-related activities.

HIV infection among sex workers in Accra: need to target new recruits entering the trade

OBJECTIVE

Description of the epidemiology of HIV infection among sex workers (SW) in Accra, Ghana.

METHODS

In all, 1013 SW working out of their homes ( seaters ) or finding customers in bars, hotels, brothels or on the street ( roamers ) were interviewed and tested for HIV.

RESULTS

Overall, prevalence of HIV infection was nearly 50% (506 of 1013), varying from 26% (133 of 507) among the roamers to 74% (368 of 496) among the seaters. Profound differences were noted between these two categories of SW with regard to age, number of clients per day, price per instance of intercourse, condom use, and other characteristics. Respectively, 27% and 58% of roamers and seaters were infected with HIV within their first 6 months of sex work, despite a limited number of unprotected sex acts with seropositive clients. Independent risk factors for HIV infection varied between types of SW: age among the roamers; region of origin and duration of sex work among the seaters; number of clients per day, and presence of current or past genital ulcer and gonococcal cervicitis in both groups.

CONCLUSION

In Accra, considerable heterogeneity exists in the population of SWs. In both categories of SW, new recruits become rapidly infected with HIV after entering the trade. The 25-fold higher prevalence of HIV among SWs than in the general adult population suggests that in Accra, as in many cities of West Africa, a high fraction of new cases of HIV infection continue to be acquired from SWs. Intervention programs targeting SW should be an essential component of national AIDS control strategies. Special efforts should be made to identify and offer preventive services to new sex workers.

Test-retest reliability for self-reports of sexual behavior among Thai and Korean respondents

The purpose of this study was to examine the test-retest reliability for reports of sexual behavior from the National Institutes of Mental Health Multisite HIV Prevention Trial survey for two Asian samples. Thai (N = 37) and Korean (N = 46) respondents aged 19-37 years (M = 29, SD = 4.61) completed face-to-face interviews to assess their sexual risk in their ethnic language 3-7 days apart. Test-retest coefficients ranged from .65 to 1.00 demonstrating acceptable reliability of the survey among Thai and Korean adults. The discussion focuses on the development of HIV risk assessments that take into consideration ethnic diversity found within the Asian and Pacific Islander community.

Behavioural and serological human immunodeficiency virus risk factors among female commercial sex workers in Cambodia

BACKGROUND

The spread of human immunodeficiency virus (HIV) in Cambodia is mainly caused by sexual transmission and the high-risk group in this country are female commercial sex workers (CSW). There are two types of CSW, direct CSW (DCSW) and indirect CSW (IDCSW), who are different from each other in sexual activities. This study was conducted in order to describe the risk factors on HIV for each type of CSW, and to establish effective preventive strategies against the HIV epidemic among CSW.

METHODS

The participants, 143 DCSW and 94 IDCSW, were interviewed using a questionnaire to determine their demographic characteristics and behaviour. Blood samples were taken for serological tests on HIV, Chlamydia trachomatis and syphilis. The association between their behavioural pattern and their serological results was analysed.

RESULTS

The questionnaire study showed that IDCSW had a riskier behavioural pattern than DCSW. The HIV seroprevalence rates of the DCSW and the IDCSW were 52.4% and 22.3%, respectively. Univariate logistic analyses showed a significant association between HIV antibody (HIV-Ab) and current age, age at commencement of commercial sex work, duration of commercial sex work, and the seropositivity of Chlamydia trachomatis-IgG antibody (CT-IgG-Ab) among the DCSW. The analyses also showed a significant relationship between HIV-Ab and CT-IgG-Ab among the IDCSW.

CONCLUSIONS

Improving condom use rate is very important in order to prevent an HIV epidemic among the two types of CSW. This study also suggests it is important to prevent sexually transmitted disease (STD) such as Chlamydia trachomatis infection. The STD control programme could be efficient for HIV prevention, especially among DCSW.

A comparison of two dosing regimens of zidovudine in Thai adults with early symptomatic HIV infection. Conducting clinical HIV trials in South-East Asia

AIM

To compare the clinical and immunological efficacy, and tolerance of two dosage regimens of zidovudine (ZDV) in an adult Thai population with early symptomatic human immunodeficiency virus (HIV) disease and to identify important clinical issues associated with conducting HIV trials in South-East Asia.

METHODS

HIV-infected Thai adults, with early symptomatic HIV disease and CD4 lymphocyte counts less than 400/mm3, who were managed in the infectious diseases clinics at two university teaching hospitals in Bangkok, Thailand, were enrolled in a randomised, open-label, dose-regimen comparison trial of ZDV. Two oral ZDV dosing regimens: regimen A, 100 mg tid+200 mg nocte (ZDV-A) vs regimen B, 250 mg bid (ZDV-B) were compared. The main outcome measures were: 1. Clinical efficacy: rate of progression to acquired immunodeficiency syndrome (AIDS) or death. 2. Immunologic efficacy: changes in CD4 lymphocyte numbers compared to baseline; rate of decline of CD4 lymphocyte numbers to less than 100/mm3. 3. Toxicity, as defined by clinical symptomatology and laboratory parameters.

RESULTS

Two hundred and four patients were enrolled (103 ZDV-A; 101 ZDV-B) of whom 195 were followed beyond baseline. Patients were typical of those encountered with HIV in Thailand: mean age 33 years; 89% male; 88% heterosexual HIV acquisition; mean baseline CD4 lymphocyte count 241/mm3. Follow-up while on therapy was comparable for the two groups (mean+/-SD): 533+/-236 days (ZDV-A) vs 592+/-210 days (ZDV-B). One hundred and eleven patients (57%; 51 ZDV-A; 60 ZDV-B) were treated for at least 22 months (669+/-30 days). Clinical and immunological outcomes for ZDV-A and ZDV-B, including rate of progression to AIDS or death, development of non-AIDS-defining opportunistic infections, mean changes in CD4 lymphocyte numbers/mm3, difference in area under the CD4:time distribution curve and difference in the rate of decline of CD4 lymphocyte numbers to less than 100/mm3, were not significantly different. The presence of oral hairy leukoplakia or unintentional weight loss of 10-20% at enrollment were significantly associated with the later development of AIDS (p=0.03 and 0.04, respectively). ZDV-associated toxicity was similar for both regimens. Maintaining protocol adherence and appropriate clinical follow-up emerged as important practical issues.

CONCLUSION

In Thai adults, ZDV 100 mg tid+200 mg nocte and ZDV 250 mg bid have similar clinical and immunological efficacy. Rates of ZDV toxicity are comparable to those reported in non-Asian populations. Despite limitations in medical care access and maintaining long-term follow-up, successful trials of antiretroviral agents are feasible in South-East Asia and multi-drug treatment trials should be pursued in appropriate institutions.

Risky business: health and safety in the sex industry over a 9 year period

OBJECTIVES

To assess whether a previously established low sexually transmitted infection/HIV risk in prostitutes in London has been sustained, and to measure other occupational risks, including mortality.

DESIGN

9 year prospective study in west London.

SUBJECTS

402 prostitutes recruited from 1985 to 1991, 320 were followed up for 675 person years to 1994.

MAIN OUTCOME MEASURES

Condom use in commercial and non-commercial sex; viral and bacterial sexually transmitted infection at initial and follow up visits; death.

RESULTS

Condom use increased significantly from 1986 to 1993 and protected the majority of commercial sexual contacts. Baseline prevalence: HIV 1.3%, hepatitis C 6.7%, hepatitis B 6.6%, syphilis 2.3%, HTLV-I/II 0.4%, gonorrhoea 3.0%, chlamydia 8.2%, genital herpes 16.8%. Incidence (per 100 person years): HIV 0.2, hepatitis C 0.3, gonorrhoea 5.6, chlamydia 12.6, genital herpes 6.5. Viral infections were associated with injecting drug use and non-British nationality; bacterial infections were associated with numbers of non-commercial partners but not with sexual contacts at work. Four women died during the course of the study; two had AIDS, two were murdered. This mortality of 5.93 per 1000 person years was 12 times the expected rate for women of a similar age.

CONCLUSIONS

This study shows that it is possible to have a larger number of sexual partners and remain free from sexually transmitted infections provided that condoms are used consistently: there has been a sustained increase in condom use in the sex industry. None the less, prostitutes are at increased risk of sexually transmitted infections, primarily through non-commercial sexual partnerships. Infectious diseases are only one of the risks facing prostitutes, as illustrated by the mortality from violence as well as from HIV infection.

Knowledge, attitudes and practices concerning HIV/AIDS among sex workers in Phnom Penh, Cambodia

The human immunodeficiency virus (HIV)/AIDS epidemic is currently spreading faster in Cambodia than anywhere else in Asia. Heterosexual transmission of HIV through prostitution is believed to be catalyzing the epidemic, and sex workers (SWs) are at a very high risk for becoming infected with HIV and subsequently developing AIDS. In order to gain a better understanding of the knowledge, attitudes and practices of this highly vulnerable population, face-to-face interviews were conducted with SWs (N = 502) in the capital city, Phnom Penh. The SWs surveyed were predominantly young, uneducated, poor women from rural areas, many of whom remain isolated in brothels. Brothel-based SWs are probably at greatest risk for acquiring HIV. They reported twice as many sexual contacts per day and used condoms less frequently than community-based SWs. The majority of SWs surveyed knew that condoms offered protection against HIV/AIDS, although one-quarter of SWs did not always use condoms. Despite their high level of baseline HIV/AIDS knowledge, nearly all SWs requested that additional health education materials be made available to them and their customers.

HIV-related sexual risk assessment among Asian/Pacific Islander American women: an inductive model

Current HIV/AIDS rates among Asian/Pacific Islander (A/PI) women in the United States are disproportionately low (CDC, 1998). However, there is evidence to suggest that risk for HIV is present, based upon studies on risk behaviors and markers for risk as well as demographic factors that may facilitate transmission among this population. Because a particular threat to A/PI women is heterosexual transmission, which accounts for nearly half of all cases (CDC, 1998), prevention efforts should focus on risk within sexual contexts and how such risk is assessed and acted upon. Using a qualitative methodology, the present study investigated how A/PI American women assess their HIV-related risk in sexual interactions. Based on extensive interview data, an inductive model of risk assessment was generated consisting of cultural and sexual risk schemata. Findings suggest the influence of cultural schemata on sexual risk schemata, which in turn influence whether condoms or HIV tests are requested. Specifically, the cultural values of reticence regarding sex, the accommodation of others and a traditional romantic ideal inhibit open discussion with partners about HIV as well as requests for safer sex behaviors. Instead, A/PI women tend to engage in non-explicit, inferential assessments of partners' risk, which may contribute to an illusory sense of control and safety. Consistent with previous studies on other groups of women, these findings further extend and elucidate theory and prevention strategies for this population.

HIV-1 and other sexually transmitted infections in a cohort of female sex workers in Chiang Rai, Thailand

OBJECTIVES

To determine demographic and behavioural factors and sexually transmitted infections (STIs) associated with prevalent HIV-1 infection among brothel based and other female sex workers (FSWs) in Chiang Rai, northern Thailand.

METHODS

Data were collected from questionnaires, physical examinations, and laboratory evaluations on Thai FSWs enrolled in a prospective cohort study in Chiang Rai, Thailand, from 1991 to the end of 1994.

RESULTS

HIV-1 seroprevalence was 32% among 500 women: 47% for 280 brothel workers and 13% for 220 other FSWs (p < 0.001); 96% of infections were due to HIV-1 subtype E. At enrolment, other STIs were common: chlamydia, 20%; gonorrhoea, 15%; active syphilis (serological diagnosis), 9%; genital ulcer, 12%; seroreactivity to Haemophilus ducreyi, 21%, and herpes simplex virus type 2 (HSV-2), 76%. On multiple logistic regression analysis, HIV-1 was associated with brothel work, birth in upper northern Thailand, initiation of commercial sex at < 15 years of age, syphilis, HSV-2 seropositivity, and genital ulcer.

CONCLUSIONS

Young Thai FSWs working in brothels in northern Thailand in the early phase of the HIV epidemic have been at very high risk for HIV-1 infection and several other STIs. Programmes are needed to prevent girls and young women from entering the sex industry and to reduce the risk of infection with HIV-1 and other STIs.

[Prevalence and risk factors associated with syphilis in women]

INTRODUCTION

Although the incidence of syphilis is generally low, it remains an important global public health problem, given its interaction with other sexually transmitted diseases (STDs). It has been shown that syphilis, due to the genital ulcers it produces, is a co-factor for acquiring other STDs, principally those of viral origin such as herpes simples type 2, hepatitis B and HIV. Many female commercial sex workers (FCSW) in Mexico have been found to have acquired good levels of knowledge about STD prevention. Nevertheless, they constitute a heterogeneous group in terms of socio-economic level, health status and type of work site; these factors in turn appear to determine their attitudes, knowledge and behavior related to acquiring and transmitting STDs, including syphilis. This study, therefore, focused on the factors associated with Treponema pallidum infection in this group of women.

METHOD

Based on a sample frame of sites where female commercial sex work takes place within Mexico City, a sample of 807 FCSWs was selected; after providing informed consent, they completed a structured questionnaire. A blood sample for identifying serologic markers for STDs was collected and analyzed according to a procedure manual for STD diagnosis. Treponema pallidum was diagnosed using the RPR (Bigaux Diagnostica) screening test, and FTA-ABS (Pasteur Diagnostics) for confirmation.

RESULTS

The prevalence of syphilis in this sample of FCSWs was 6.4% (52/807), and was higher among women who worked at street sites than among those who worked in massage parlors. The age of the women interviewed ranged from 17 to 58 years, with a mean of 29.2 years (SD 7.3 years); syphilis was more prevalent among women over 30 years of age. Age at first sexual intercourse ranged from 11 to 30 years, with a mean of 16 years (SD 3.1 years), which is similar to that of the general female population in Mexico. Predictive factors for T. pallidum infection, determined adjusted logistic regression, included: tupe of by work site (bar and street sites); socio-economic level (middle and low); age (over 30 years); duration of involvement in sex work (> 5 years) and number of clients per week (> 10).

CONCLUSION

In spite of some limitations regarding statistical precision, this study shows that FCSWs are heterogeneous in terms of risk of acquiring STDs, including syphilis; the principal differentiating factor was shown to be the type of work site. Given that it is not belonging to a risk group but rather participating in risky practices that leads to acquiring STDs, situations that facilitate riskier or safer practices (such as type of sex work site, for sex workers) should be taken into account when studying people's risk level. STD prevention campaigns must also consider these factors, in addition to focusing on FCSWs and their clients and personal partners, so that all involved assume their responsibility for safer sex.

HIV-1 seroconversion in a prospective study of female sex workers in northern Thailand: continued high incidence among brothel-based women

OBJECTIVES

To determine the incidence of HIV-1 infection, temporal trends in incidence, and risk factors for seroconversion in a cohort of female commercial sex workers (CSW) in upper northern Thailand, the region of Thailand with the highest rates of HIV-1 infection.

METHODS

CSW were enrolled from 1991 through 1994 and evaluated prospectively with interviews, physical examination, testing for sexually transmitted diseases (STD), and serologic testing for HIV-1 infection.

RESULTS

The incidence of HIV-1 seroconversion in the first year of follow-up was 20.3 per 100 person-years among 126 brothel-based CSW and 0.7 per 100 person-years among 159 other CSW who worked in other venues such as bars or massage parlors. Incidence remained elevated among brothel-based CSW who were enrolled later in the study compared with those who enrolled earlier. Through 1996, 30 women seroconverted. In a multivariable proportional hazards model, seroconversion was significantly associated (P < 0.05) with brothel-based sex work (adjusted risk ratio, 7.3) and Chlamydia trachomatis cervical infection (adjusted risk ratio, 3.3).

CONCLUSION

Despite national HIV control efforts and declining rates of infection among young men in Thailand, brothel-based CSW may continue to be at high risk for HIV-1 infection. Additional efforts are needed to provide alternative economic choices for young women, to ensure universal condom use during commercial sex, and to develop new prevention technologies.

Decreasing incidence of HIV and sexually transmitted diseases in young Thai men: evidence for success of the HIV/AIDS control and prevention program

OBJECTIVE

To determine whether HIV and sexually transmitted disease (STD) incidence rates among young men in northern Thailand have declined since the establishment of the '100% Condom Program', and to prospectively document changes in the association between behavioral risk factors and incident HIV and STD infections.

SETTING

Thirteen military bases in northern Thailand.

METHODS

Serial prospective cohorts of 19-23-year-old male conscripts (n = 4086) inducted into military service from six northern Thai provinces between 1991 and 1993 were followed at 6-month intervals for incident HIV and STD through May 1995. HIV incidence was determined by serology, and incident STD were reported by conscripts as diagnosed by health-care providers.

RESULTS

HIV incidence declined from a rate of 2.48 per 100 person-years during 1991-1993 to 0.55 per 100 person-years during 1993-1995. STD incidence showed an even greater decline, with a 10-fold decrease from 1991-1993 to 1993-1995. Behavioral risk factors for incident STD infections included a history of prior STD and sex with girlfriends and sex workers. Inconsistent condom use remained a strong predictor of incident STD among brothel visitors. Other previously-reported risk factors in 1991-1993 such as illicit drug use, frequency and cost of brothel visits, and low socioeconomic status were not associated with incident STD or HIV in 1993-1995.

CONCLUSIONS

Although several studies have recently reported decreased prevalence of HIV and STD infections in Thailand, these data demonstrate that a dramatic decrease in the incidence rates of STD, including HIV infection, has occurred among young men in military service in northern Thailand. The Thai AIDS prevention and control program might be implemented by other countries experiencing major epidemics of heterosexually transmitted HIV infections. Similar prevention programs targeted at other populations in Thailand and elsewhere in Asia are needed to decrease the spread of the HIV epidemic.

Sex workers and the control of sexually transmitted disease

OBJECTIVES

To describe and assess measures to control sexually transmitted diseases (STDs) among sex workers and their partners.

METHODS

A review of medical, historical and social literature, focusing on selected cases.

RESULTS

Measures to control disease in sex workers today are often prompted by concerns about HIV transmission. However, the literature shows that prostitution varies from one place and time to another, together with the risk of sexually transmitted disease. A broad social definition of prostitution rather than a narrow reference to levels of sexual activity is important for effective disease control, as an understanding of the relation between social disadvantage and sexual activity enables the provision of occupational services that sex workers actually want and use. Social prejudice and legal sanctions cause some sex workers and their partners to avoid even the most appropriate and accessible specialist services. Therefore targeted programmes can only complement, and not replace, general measures to control STDs, which are developed for other social groups or the local population as a whole.

CONCLUSIONS

Sex workers and sex work differ from one place to another and so a single model for STD control is inappropriate. None the less, occupational health risks suggest a general need for specialist services. Where these do not compound the disadvantages that sex workers already suffer, medical services are likely to offer significant benefits in prevention, early diagnosis, and treatment of STDs. As the stigma of prostitution leads many people to remain invisible to services, a general health infrastructure and anti-discriminatory measures will be equally important to effective disease control.

HIV-1 infection among female commercial sex workers in rural Thailand

OBJECTIVE

To reconstruct past HIV-1 incidence and identify risk factors for HIV-1 seroconversion among female commercial sex workers in a semi-rural setting in northern Thailand.

DESIGN

Retrospective cohort of sex workers attending a sexually transmitted disease (STD) clinic at Mae Chan District Hospital, Chiang Rai Province, Thailand.

METHODS

Information included demographic data, HIV-1 antibody testing and STD diagnosis was collected in 821 sex workers attending the STD clinic from 1989 through 1993. HIV-1 incidence among initially HIV-1-seronegative sex workers who underwent repeat HIV-1 antibody testing during follow-up was determined and possible predictive factors for seroconversion including diagnosis of other STD were examined.

RESULTS

HIV-1 seroprevalence among 556 sex workers who underwent antibody testing was 52%, rising from 29% at initial test in 1989 to 53-63% for 1990-1993. Among 96 initially HIV-1-negative sex workers who underwent repeat testing, 64 HIV-1 seroconversions occurred, giving an incidence rate of 12.6/100 person months (PM). Incidence increased from 12.0/100 PM for 1989 and 1990 to 17.0/100 PM for 1991, with a subsequent decline to 9.3/100 PM for 1992-1993. The cumulative risk of seroconversion 6 months following initial negative HIV-1 antibody test was 57%. There were higher rates among younger sex workers (14-19 years old) and those from Hilltribes, but only a diagnosis of chancroid was significantly associated with HIV-1 seroconversion (P = 0.014).

CONCLUSION

An explosive epidemic of HIV-1 occurred among sex workers in a semi-rural area of northern Thailand from 1989. These HIV-1 incidence estimates, which are among the highest rates of sexual transmission ever reported, highlight the extreme vulnerability of female sex workers to HIV infection, even in a non-urban setting.

Changes in sexual behavior and a decline in HIV infection among young men in Thailand

BACKGROUND

In Thailand the epidemic of human immunodeficiency virus (HIV) infection is of recent origin. Because of the high seroprevalence of HIV among sex workers, the Ministry of Public Health began a program in 1990 and 1991 to promote the use of condoms during commercial sex. We evaluated the effect of this and other programs to prevent HIV infection in Thailand.

METHODS

Using direct interviews, we studied five cohorts of 21-year-old men from northern Thailand who were conscripted into the army by a lottery in 1991, 1993, and 1995. In all, 4311 men were tested for HIV antibodies by enzyme-linked immunosorbent assay, with confirmation by Western blot assay.

RESULTS

In the 1991 and 1993 cohorts, the prevalence of HIV infection was 10.4 to 12.5 percent. In 1995, it fell to 6.7 percent (P < 0.001). The seroprevalence was only 0.7 percent among men who did not have sexual relations with a sex worker before 1992. Over the study period, the proportion of men who reported having sexual relations with a sex worker fell from 81.4 percent to 63.8 percent (P < 0.001). From 1991 to 1995, the men's reported use of condoms during the most recent sexual contacts with sex workers increased from 61.0 percent to 92.5 percent (P < 0.001); and in 1995, 15.2 percent of men had a history of a sexually transmitted disease, as compared with 42.2 percent in 1991 (P < 0.001).

CONCLUSIONS

Public health programs in Thailand have led to substantial changes in sexual behavior among young men, especially an increased use of condoms, and the rate of new HIV infections has declined.

Epidemiologic risk factors for incident sexually transmitted diseases in young Thai men

BACKGROUND AND OBJECTIVES

Prospective studies of incidental sexually transmitted diseases in developing countries rarely have been reported. As the human immunodeficiency virus epidemic widens, knowledge of the epidemiology of sexually transmitted diseases as co-factors for human immunodeficiency virus infection is viewed as vitally important.

GOAL

To determine epidemiologic risk factors for incidental sexually transmitted diseases in young men in northern Thailand.

STUDY DESIGN

A cohort of 2,417 men selected by lottery for military conscription was followed an average of 22 months, with epidemiologic risk factors and sexually transmitted disease histories assessed semiannually. Sexually transmitted diseases were determined by physician or symptom histories obtained by interview.

RESULTS

Sexually transmitted disease incidence was 17.04 per 100 person-years. Gonorrhea and chancroid were commonly reported, whereas incident syphilis was rare. Sexually transmitted disease incidence declined significantly in the 2-year period. Most sexually transmitted diseases were acquired through commercial sex patronage. However, among men who did not report visiting a brothel, there was a significant increase in sexually transmitted diseases among men reporting sex with a girlfriend. Other risk factors included inconsistent condom use, drug use, and low educational level. Frequent alcohol use was associated with incident sexually transmitted diseases in bivariate analysis, but drinking at the time of last brothel visit was not associated with increased sexually transmitted diseases.

CONCLUSIONS

Sexually transmitted disease control in Thailand is based on an integrated sexually transmitted disease clinic system. Many commercial sex workers are examined and treated routinely, but too infrequently to reduce sexually transmitted disease transmission between them and their male clients. Condom-use levels in commercial sex settings still may be too low to reduce sexually transmitted disease transmission. More consistent and effective sexually transmitted disease treatment of commercial sex workers and their clients and education of men on the effective and consistent use of condoms is required to reduce the risks of sexually transmitted disease transmission in this population.

Malaria and Casual Sex: What Travelers Know and How They Behave

Background: Travelers to the tropics have been reported to comply poorly with recommendations regarding malaria and AIDS. This study addresses the problem of influencing travelers' behavior through different approaches to conveying advice. Method: 3509 people attending a large travel clinic were randomly allocated to different interventions, including brochures about the implications of "sex tourism" and the possibility of participating in a contest assessing knowledge of malaria and AIDS. A comparison group (n = 607) of travelers to Kenya was contacted at an airport. Anonymous, self-administered questionnaires were sent to all travelers after their return. Results: Compliance with chemosuppressive regimen for malaria was 87%. Well-informed travelers did not protect themselves more efficiently against malaria. The efficacy of a given intervention was found to vary according to the age, sex, or travel experience of the participants. Of travelers, 51% reported casual sex abroad (M/F: 69/31). Thirty-eight percent of these contacts were unprotected. Casual sex abroad and condom use were correlated with a history of casual sex in the home country. Condom use was especially low in young women, who were also more likely to have casual sex with fellow travelers than with local partners. Eight percent of the "sex tourism" brochure readers had engaged in casual sex with local partners (all travelers, 4%). Conclusions: Lack of knowledge does not appear to be the problem. Travelers need to be motivated to put their knowledge into practice. Our results suggest that risks relating to malaria and AIDS are perceived in a different manner and that counseling should be individualized. Contest questions can help start a discussion on ethical and health-responsible behavior. The target group of the "sex tourism" brochure was reached, but their behavior appears not to have changed. Objective criteria can help physicians recognize "high-risk" travelers. Travelers need to be made aware that they may encounter environments conducive to risky behavior and that, while abroad, they may react in unexpected ways.

Risk behaviour and STD acquisition in genitourinary clinic attenders who have travelled

OBJECTIVE

To investigate the travel history of clients presenting at a genitourinary medicine (GUM) clinic in order to assess the contribution made by sexual partnerships abroad to STD transmission in the UK.

SUBJECTS

386 old and new clients who attended during a 3-month period and who had travelled abroad in the 3 months preceding their visit.

METHODS

All participating clients self-completed a confidential questionnaire, the results of which were then linked to their clinical diagnosis (if any).

RESULTS

25% of participants reported a new sexual partner during their most recent trip abroad. In comparison to those not reporting a new partner, they were more likely to be male, travelling alone, to have visited the clinic previously and to have no regular sexual partner. Two-thirds reported never or inconsistently using condoms with these new partners. A total of 11.6% of the STDs diagnosed in the study participants may have been acquired abroad.

CONCLUSION

We have found a high rate of new sexual relationships reported by attendees at our GUM clinic, and a low rate of reported condom use. With high HIV incidence rates in many tourist regions, the need for further studies to establish the true extent of imported STDs in the UK is a priority, and primary prevention campaigns to inform travellers are of paramount importance.