Behavioral surveillance and factors associated with condom use and std incidences among the male commercial sex client population in Hong Kong--results of two surveys

Trend and Factors Associated with Condom Use Among Male Clients of Female Sex Workers in Hong Kong: Findings of 13 Serial Behavioural Surveillance Surveys

This study investigated the trend and associated factors of condom use among male clients of female sex workers (CFSW) in Hong Kong. A total of 25,443 males of the general population were screened to identify 2,330 CFSW via 13 rounds of population-based serial cross-sectional telephone surveys during 1998 through 2015. Over time, there were no significant changes in condom use with various types of female sex partners (p ranged 0. 219-0.837) and prevalence of self-reported STI (p = 0.975) in the past 6 months. Decrease in the prevalence of non-regular sex partners (p < 0.001) and increase in perceived efficacy of condom use for HIV prevention (p = 0.028) were observed. Perceived efficacy of condom use for HIV prevention and self-reported STI experience were significantly associated with condom use with various types of female sex partners in the past 6 months. No evident improvement for condom use was found. Tailored intervention programs are warranted.

A meta-analysis and systematic literature review of factors associated with sexual risk-taking during international travel

BACKGROUND

International travel facilitates global spread of sexually transmitted infections (STI). Travellers could contribute to onward transmission of pathogens rarely encountered at home and export new strains to the destination. The aim was to systematically examine evidence regarding determinants of travel-related sexual risk-taking and identify knowledge gaps and areas for targeted interventions.

METHOD

Articles published in peer-reviewed journals from 2000 to 2017 were screened in 6 databases and assessed for relevance against criteria. Data was extracted for factors associated with travel-related STI or proxies. Meta-analyses estimated pooled prevalence of casual sex and non-condom use. Adjusted odds ratios of predictors were pooled to generate a combined estimate.

RESULT

Forty-nine articles qualified for inclusion. A heterogeneity test indicated variation across studies. The pooled prevalence of casual travel sex was 35% and prevalence of non-condom use 17%. Expectations of casual sex strongly predicted sex with a new partner when travelling abroad. Planning to have sex indicated condom use.

CONCLUSION

The studies largely represented sub-groups of risk-taking populations from a European context, indicating substantial knowledge gaps. Studies investigating migrants travelling to visit friends and relatives, older travellers, and female travelers are needed. Post-travel harm reduction activities may serve as a focus for future interventions.

Male Clients of Male Sex Workers in China: An Ignored High-Risk Population

Background:

There is a high prevalence of HIV/syphilis among male sex workers, but no formal study has ever been conducted focusing on male clients of male sex workers (MCM). A detailed investigation was thus called for, to determine the burden and sociobehavioral determinants of HIV and syphilis among these MCM in China.

Methods:

As part of a multicenter cross-sectional study, using respondent-driven and snowball sampling, 2958 consenting adult men who have sex with men (MSM) were recruited, interviewed, and tested for HIV and syphilis between 2008 and 2009. The distributions of sociodemographic characteristics, risk behaviors, and HIV/syphilis prevalence were determined and compared between MCM and other MSM.

Results:

Among recruited MSM, 5.0% (n = 148) were MCM. HIV prevalences for MCM and other MSM were 7.4% and 7.7%, whereas 18.9% and 14.0% were positive for syphilis, respectively. Condomless anal intercourse (CAI) was reported by 59.5% of MCM and 48.2% of MSM. Multiple logistic regression revealed that compared with other MSM, MCM were more likely to have less education [for ≤elementary level, adjusted odds ratio (aOR) = 3.13, 95% confidence interval (95% CI): 1.42 to 6.90], higher income (for >500 US Dollars per month, aOR = 2.97, 95% CI: 1.53 to 5.77), more often found partners at parks/restrooms (aOR = 4.01, 95% CI: 2.34 to 6.85), reported CAI (aOR = 1.49, 95% CI: 1.05 to 2.10), reported a larger sexual network (for ≥10, aOR = 2.70, 95% CI: 1.44 to 5.07), and higher odds of syphilis (aOR = 1.54, 95% CI: 1.00 to 2.38).

Conclusions:

The greater frequency of risk behaviors and high prevalence of HIV and syphilis indicated that HIV/syphilis prevention programs in China need to pay special attention to MCM as a distinct subgroup, which was completely ignored until date.

Condom Use, Sexual Risk, and Self-Reported STI in a Sample of Older Male Clients of Heterosexual Prostitution in the United States

While there is evidence of increasing rates of sexually transmitted infections (STIs) among older men in the United States, there has been little research on older male clients of female sex providers. The purpose of the current study was to understand the sexual risk behaviors and psychosocial correlates among older men hiring sex providers through provider review websites and discussion boards. A convenience sample of 208 male clients ages 60 to 84 completed online surveys about their sexual behavior and psychosocial factors. Participants indicated the most common sexual activities with providers in the past 12 months were receiving condomless fellatio (33.7%) and having penile-vaginal intercourse with a condom (31.7%). Although condomless penile-vaginal sex with a provider in the past 12 months was only reported by 2.9%, about half (51%) of the respondents indicated that they had experienced this at least once during their lifetime. This was associated with a preference for providers who do not require condoms, having been previously diagnosed with an STI, and perceiving one's HIV risk to be higher, as well as advancing age and having more emotional relationships with providers. Findings demonstrate the need for general and sexual health care practitioners to openly discuss protective measures and strategies for avoiding STIs among their older-to-elderly male patients.

Contexts of HIV-Related Risk Behaviors among Male Customers at Asian Massage Parlors in San Francisco

Based on focus groups for male customers who frequented Asian massage parlors in San Francisco, the present study described their sexual and drug use behaviors and attitudes toward practicing safe sex with Asian masseuses. A pervasive view among patrons was that they could engage in sex with masseuses without using a condom if they offered extra money. Their sexual behaviors with Asian masseuses were influenced by perceptions about vulnerability toward HIV/STIs, substance use behaviors, and masseuses’ initiation of condom use, which was often governed by unspoken rules at parlors. Customers perceived massage parlors as being a safe place compared with street sex venues. Some customers sought emotional attachment with Asian masseuses and expressed stereotypical views toward them as being docile and submissive. Culturally appropriate HIV/STI prevention programs (e.g., communication about and practicing 100% condom use) are needed to target both customers and Asian masseuses at multiple levels (individual, owner/manager, work environment, and community levels). Also, customers’ and masseuses’ perceptions toward relationships at massage parlors and power dynamics need further investigation to promote safe work environments and 100% condom use at massage parlors.

Awareness and acceptability of female condoms among monogamous Hong Kong Chinese female sexually transmitted infection patients

Female condom is an effective means of HIV prevention. Monogamous female sexually transmitted infection (STI) patients are exposed indirectly to high risk of contracting HIV/STI via their sole male sex partners. There are few interventions to protect such women whilst female condom use is a potential means of self-protection. With informed consent, this cross-sectional study investigated the prevalence of awareness and acceptability of female condoms among 335 Chinese monogamous female STI patients attending a government STI clinic in Hong Kong. Among those who were aware of female condoms (66.9 % of the sample), 68.3 % were willing to use free female condoms. Awareness was associated with having the sex partner being a boyfriend (OR = 3.76, P < 0.001), knowledge about asymptomatic property of HIV (OR = 2.14, P = 0.006) and no immunity for STI (OR = 2.14, P = 0.011), experience of HIV antibody testing (OR = 2.21, P = 0.004) and unemployment (OR = 0.50, P = 0.011). Among those who had heard of female condoms, acceptability was associated with knowledge about possibility to contracting two STI concomitantly (OR = 2.26, P = 0.03) and perceived chance of contracting STI from the sex partner in the coming 6 months (OR = 2.27, P = 0.04). Awareness is relatively low but the prevalence of acceptability is encouraging. Female condoms have been underused and should be promoted among monogamous female STI patients as a means of empowerment as an option for sex protection.

Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in high-income countries

BACKGROUND

Interventions to change behaviour among sex workers and their clients have been identified as a strategy to reduce HIV transmission. However, there has been no systematic review that has examined and summarized their effects.

OBJECTIVES

To identify and evaluate the effects of the studies performed on behavioural interventions to reduce the transmission of HIV infection among sex workers and their clients in high-income countries.

SEARCH METHODS

Electronic searches were undertaken using MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) and other databases between January 1980 and July 2010. Experts in the field were contacted to locate any other studies.

SELECTION CRITERIA

Randomised controlled trials or specified quasi-experimental designs with comparison groups that examined the effects of behavioural interventions aimed at reducing the risk of HIV or sexually transmitted infections (STIs) transmission among sex workers in high-income countries. We reviewed studies for outcome relevance and methodological rigor.

DATA COLLECTION AND ANALYSIS

Two reviewers independently applied the inclusion criteria to potential studies, and any disagreements were resolved by discussion. Studies were assessed for completeness of reporting and extracted data.

MAIN RESULTS

A total of four studies were included, comprising two randomised controlled trials and two quasi-experimental pretest-posttest trials with control groups involving 1795 participants. No trials reported HIV prevalence/incidence as outcomes.Overall, the effects of behavioural interventions for sex workers in high-income countries on STI incidence did not differ significantly among two studies using a random effects model (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.11 to 1.98). Only one study found that the self-reported STI prevalence in clients of female sex workers was statistically significant (RR 0.09, 95%CI 0.01 to 0.72, P=0.02). There was no significant difference after behavioural intervention for condom use. Two studies demonstrated the effectiveness of intervention for knowledge of HIV transmission among sex workers (RR 1.82, 95%CI 1.55 to 2.14) and clients of sex workers (RR 1.93, 95%CI 1.46 to 2.55).

AUTHORS' CONCLUSIONS

There is limited evidence from randomised controlled trials for the effectiveness of behavioural interventions to reduce the transmission of HIV infection among sex workers and their clients in high-income countries. Further randomised controlled trials are very likely to have important impacts on our confidence in the estimates of the effects, and are likely to change the estimates for effective interventions with outcomes of HIV incidence or prevalence and a variety of different settings among sex workers and their clients in high-income countries. Randomised controlled trials that test for the identification of effective interventions for HIV prevention with outcomes of biological endpoints, such as HIV incidence or prevalence, are needed for these neglected populations. More research is also needed for male or transgender sex workers and their clients in high-income countries.

Psychosocial pathways to inconsistent condom use among male sex workers: personality, drug misuse and criminality

BACKGROUND

This research compared street male sex workers in Santo André, Brazil, that reported consistent condom use with those that revealed inconsistent condom use with their clients, concerning personality aspects, impulsiveness, alcohol and drug consumption, depressive symptoms, sociodemographic data and criminal involvement.

METHODS

Eighty-six male sex workers were evaluated in face-to-face interviews at their place of work. A 'snowball' sampling procedure was used to access this hard-to-reach population.

FINDINGS

Male sex workers with inconsistent condom use showed greater involvement with criminal activities, higher reward dependence level and more frequent self-report of being HIV-positive.

CONCLUSIONS

Conceptualisation of male sex workers' psychological characteristics may be required where HIV risk is not only attributed to sex work per se, but to other aspects such as personality-related factors and negative identity.

Identifying the psychosocial correlates of condom use by female sex workers in Hong Kong

This study examined factors affecting condom use by Hong Kong female sex workers when they have sex with their clients and steady partners. Our respondents consisted of 109 active female sex workers, mainly streetwalkers or sex workers who worked in villas. During a 30-minute interview, respondents were interviewed individually and were asked questions regarding their condom use practice. These questions were designed to measure various factors affecting their condom use practice, including attitudes toward condom use, normative pressure, perceived behavioural control, perceived AIDS risks, past condom use behaviour, and future condom use intentions with respect to the two types of partners. Multiple regression analyses reveal that perceived behavioural control is the most important factor associated with these respondents' future condom use across the two types of partners. Perceived AIDS risk is the additional predictor for condom use with clients, while normative pressure is the additional predictor for condom use with steady partners. Past condom use behaviour also provided significant additional prediction for both types of partners, implying the habitual nature of condom use among our respondents. These results have significant implications for designing intervention programmes targeting at increasing condom use by female sex workers in Hong Kong.

Pregnant women's decisions on antenatal HIV screening in Hong Kong

Identification of HIV-infected pregnant women by antenatal screening is crucial to prevent mother-to-child transmission. In Hong Kong, little is known about women's opinions about the screening test. This cross-sectional study examines the decisions of Hong Kong Chinese pregnant women to undergo antenatal HIV screening and the reasons for their choices. Among 191 pregnant women studied, 147 (77.0%) indicated that they would opt for antenatal HIV screening if offered. Of those, 113 (76.9%) would do so for 'the health of their newborns' and 93 (63.3%) for 'their own health'. Fourteen (7.3%) would decline the test, because they have 'one stable sexual partner' (n=9, 64.3%) and believe that 'HIV infection was not their concern' (n=8, 57.1%). Women with a lower educational attainment (adjusted OR=3.77; 95% C.I., 1.12-12.67, p=0.03) were likely to choose antenatal HIV screening. Results of this study are predictive of pregnant women's responses to Hong Kong's newly enacted antenatal HIV screening programme.

Female sex workers in China: vectors of disease?

OBJECTIVE

To analyze the extent by which Chinese female sex workers (FSWs) serve as vectors of HIV/AIDS to an otherwise spared general population and to describe the implications of centering efforts solely on this high-risk group.

GOAL

By using the example of FSWs in China, we intend to demonstrate the role that structural factors can have on HIV transmission above and beyond individual high-risk behaviors.

STUDY DESIGN

Literature review of years 1980-2006.

RESULTS

Analysis of the literature suggests that major determinants of HIV transmission amongst FSWs in China include sociopolitical context, gender, work environment and finally, risky sexual behaviors.

CONCLUSIONS

Chinese FSWs live in a specific sociopolitical context that shapes their capacities to engage in safe-sex practices. Focusing on FSWs as vectors of HIV/AIDS epidemic in China neglects the larger context that endangers all members of society and blames an already vulnerable population.

HIV prevention among travelers: why do men not use condoms when they engage in commercial sex overseas?

OBJECTIVES

We investigated factors associated with condom use among men patronizing female sex workers abroad and locally.

STUDY DESIGN

We conducted a survey on 372 local men attending the only public sexually transmitted infections clinic in Singapore between 2001 and 2003.

RESULTS

Condom use was higher among clients patronizing sex workers in Singapore than those patronizing sex workers abroad (87.5% vs. 54.4%, P<0.001). Condom use in both groups was associated with initiation of condom use by the sex workers (adjusted prevalence ratios: 1.67, 95% confidence interval: 1.11-2.49; 1.87, 1.21-2.90) but was not associated with clients' knowledge of disease, self-perceived risk, confidence in condom use, and dislike of condoms. Less sex workers abroad than in Singapore (32.7% vs. 75.6%, P<0.001) initiated condom use.

CONCLUSION

Lower condom use among Singaporean travelers abroad was determined by extrinsic factors, whereby sex workers abroad were less likely to initiate condom use rather than by clients' factors.

Environmental health and safety of Chinese sex workers: a cross-sectional study

AIM

This paper presents a Hong Kong (HK) data on the effect that sex work has on women's environmental health and safety. An outreach role that highlights safety and human rights is suggested for nurses working with female sex workers (FSWs) as clients.

BACKGROUND

In HK it was estimated that there were at least 200,000 FSWs in 2002 and the total population involved as workers, support staff, clients and partners of the clients exceeded half a million in a city of 6.8 million people. Despite these numbers, both locally and internationally there are very limited outreach nursing services that address the FSW's occupational health needs.

METHOD

A cross-sectional survey, was undertaken over a 5 month period commencing in October 2003. A validated Chinese version of the World Health Organisation Quality of Life Measure was administered to a convenience sample of 89 female street sex workers. A focus group interview was later conducted to gain contextual information.

RESULTS

The predominantly mainland Chinese FSWs had a mean age of 36.1 years. These women tended to be less educated and older than the general population of FSWs. They worked long hours with most of their income sent back home to China. Many lived in sub-optimal conditions and risked being abused while at work. The women scored significantly lower in the environmental domains when compared to the general female population.

CONCLUSION

Highlighted is the critical importance of developing a new role, both international and within the Asian region, for community nurses working in an outreach capacity. This role should be visible, affordable and accessible, for at risk populations such as FSWs. The primary focus of the new role would be to establish a close working relationship between sex workers, sex industry owner/operators, health agencies and local authorities. Risk awareness programs developed and conducted by community nurses should embrace the complexity of occupational health issues. Such programs would also have the benefit of affirming the health rights of sex workers and public health.

Female street sex workers in Hong Kong: moving beyond sexual health

BACKGROUND

For many years, the sex industry in Hong Kong has appeared to be an integral and ever-expanding component of the city's sociocultural and economic structure. Accordingly, the physical and psychological health of sex workers is becoming an increasing concern for the workers themselves, the public, and government policy.

METHODS

A cross-sectional survey on the quality of life (World Health Organization Quality of Life [WHOQOL]) of female sex workers (FSWs) in Hong Kong was used to investigate the physical and psychological well-being of street FSWs, and the results were compared with those of non-sex-working Hong Kong women after adjusting for age, educational level, marital status, and health status.

RESULTS

The 89 FSWs surveyed scored significantly lower on QOL--WHOQOL-BREF (HK)--measures compared with the non-sex-working women. One common aspect among these sex workers was their negative view of themselves and of life. Many sex workers were at risk of being abused while at work, and many women worked without legal protection. Most of the women surveyed engaged in sex work to support their families. Because their income was often insufficient, some of their needs, especially those concerning health, were often neglected.

CONCLUSIONS

The low WHOQOL-BREF (HK) scores in FSWs indicate feelings of helplessness and entrapment, which may well result in detrimental effects on sex workers' health, self-esteem, and confidence when asserting their basic rights, such as access to healthcare and safety. The conclusion highlights the vulnerability of this population to apparent weaknesses in Hong Kong's current healthcare system.

HIV/AIDS Behavioral Surveillance Surveys of the Cross-Border Sex-Networker Population in Hong Kong From 1997 to 2001

BACKGROUND

Mobility is an important risk factor in the spread of HIV.

GOAL

The goal was to conduct behavioral surveillance surveys on Hong Kong males crossing the border to mainland China to have sex with female sex workers (FSW) or nonregular female sex partners who were not FSW (NRP).

STUDY DESIGN

Four surveys (1997-2001), using a special data collection method, were conducted at the Hong Kong-mainland China border checkpoint (n=5294).

RESULTS

Consistently, a notable proportion of the travelers had patronized FSW or had had sex with NRP in the preceding trip to mainland China. Inconsistent condom use was high (> or =40%) and HIV antibody testing was low (<12%). Self-perceived susceptibility of contracting HIV also was low.

CONCLUSION

No remarkable improvement on the level of risk behaviors was observed over the study period. Sustained efforts to promote safer sex and awareness of the risk associated with sex-networking are required.

The relationship between condom use, sexually transmitted diseases, and location of commercial sex transaction among male Hong Kong clients

OBJECTIVE

This study investigated the consistency of condom use and the prevalence of self-reported sexually transmitted diseases (STD) among male Hong Kong commercial sex clients with respect to the geographical location of these transactions.

DESIGN AND METHODS

Male clients were identified via three independent, population-based surveys conducted in 1998, 1999, and 2001. A unique confidential telephone system was used to collect sensitive information.

RESULTS

Respondents patronizing female sex workers (FSW) in 'mainland China only' or in 'mainland China and other places' were more likely to be inconsistent condom users (28 and 34%) than those patronizing FSW in 'Hong Kong only' (9.1%). A similar pattern was found for self-reported STD in the past 6 months (10.1, 8.1 and 1.0%, respectively). Patronizing FSW in mainland China was associated with a higher prevalence of self-reported STD (adjusted OR 4.16), independent of consistent condom use and other potential confounding factors, including calendar year of survey, age, educational attainment, HIV-related knowledge, perceived efficacy of condom use for HIV/AIDS prevention, number of female sex partners, and the presence of a regular female sex partner in the past 6 months. Clients who had commercial sex both in mainland China and Hong Kong were more likely to use condoms in Hong Kong than in mainland China (paired OR 4.67, < 0.05).

CONCLUSION

The geographical location of commercial sexual activity is related to the consistency of condom use, irrespective of the clients engaged in such activity. Prevention programmes need to be aware of how risk behaviour is dependent on local contexts.