Public health initiative nearly halves STI rates.

A 40 percent decline in rates of sexually transmitted infection, (STIs) occurred among a sample of 400 female sex workers who participated in a recent initiative to promote 100 percent condom use in 68 commercial sex establishments in two Dominican Republic cities.

Conducted over a year, the initiative--supported by the Horizons Program of the Population Council, the Johns Hopkins School of Public Health, and the AccionSIDA project of the Academy for Educational Development (AED)--involved two condom promotion approaches. The first, carried out at 34 sex establishments in Santo Domingo, encouraged solidarity among female sex workers, sex establishment owners and managers, and other employees (such as disc jockeys, bartenders, and doormen) to commit to consistent condom use in the establishments. The second approach, carried out at 34 sex establishments in Puerto Plata, was similar but also applied a regional governmental 100 percent condom use policy and a graduated sanction system directed at sex establishment owners. Both approaches were conducted not only in brothels, but also in other establishments (such as bars and discos) where sex work may occur.

STI data collected among 200 sex workers at each site before and immediately after the interventions showed at both sites comparable declines in the prevalence of one or more of three STIs (chlamydial infection, gonorrhea, and trichomoniasis). In Santo Domingo, rates declined from 25 percent to 16 percent, while those in Puerto Plata declined slightly more, from 29 percent to 16 percent.

The initiative measured condom use with new clients and with regular paying and regular nonpaying partners at both sites. Self-reported consistent condom use increased significantly in both cities. Notably, consistent condom use with new clients increased from 75 percent to 94 percent in Santo Domingo, while in Puerto Plata it more than doubled (from 13 percent to 29 percent) with regular paying and regular nonpaying partners. Additionally, observed rates of sex workers' verbal rejection of unsafe sex with clients increased significantly (from 50 percent to 80 percent) in Puerto Plata only.

"The combined community-based solidarity/governmental policy and sanction model implemented in Puerto Plata produced much higher rates of compliance with key intervention components than the solidarity-only model implemented in Santo Domingo," says Dr. Deanna Kerrigan, assistant research professor with Johns Hopkins University's Department of International Health in Baltimore, MD, USA, and a principal investigator in the study. "However, given that relatively few sanctions were levied during the intervention in Puerto Plata, the governmental policy and perhaps the threat of sanctions--rather than sanctions themselves--appear to have made this critical difference."

Creating a norm and a governmental policy endorsing consistent condom use, Dr. Kerrigan says, involved fostering relationships among members of three key groups:

* Community members, including sex workers, owners, managers, and other employees of female commercial sex establishments;

* Governmental employees, such as health inspectors, STI clinic physicians, and policy-makers affiliated with the country's national HIV/AIDS/STI control program and regional health departments; and

* Nongovernmental organizations such as the Centro de Promocion y Solidaridad Humana (CEPROSH) in Puerto Plata and Centro de Orientacion e Investigacion Integral (COIN) in Santo Domingo, both of which have conducted peer education and HIV prevention activities with sex workers in the country for more than 15 years. The national organization of sex workers, Movimiento de Mujeres Unidas-MODEMU, also participated.

The forging of such alliances generated innovative collaborations that allowed for a more comprehensive approach to HIV/ STI prevention. In the case of sex workers, a comprehensive approach and messages centered around condom use, STI services, and creating an environment that encouraged safe sex practices. As part of the Dominican Republic initiative, sex worker peer educators provided pre- and post-STI counseling at governmental STI clinics. Governmental health inspectors and employees of the nongovernmental organizations visited sex establishments to reinforce the importance of complying with monthly STI exams. Nongovernmental employees collaborated with sex worker peer educators to train governmental health inspectors and STI clinic physicians to provide guidance on improving sex workers' health care service quality.

Educational materials geared toward female sex workers, sex establishment owners and managers, employees, and clients were also developed. Solidarity among these groups was nurtured during workshops that stressed that condom use is a team effort. These activities resulted in such changes as disc jockeys routinely promoting condoms over public announcement systems at participating sex establishments in both sites.

Participatory workshops gave sex workers an opportunity to role-play how to negotiate condom use with different types of sexual partners. They focused on sex workers' condom use with both regular paying and regular nonpaying partners, with whom condom use in the Dominican Republic has been observed to be much lower than with new clients. (1) Such efforts seek to develop a norm of safer sex among a critically important group at risk for HIV/STIs.

REFERENCE

(1.) Kerrigan D, Moreno L, Rosario S, et al. Adapting the Thai 100% condom programme: developing a culturally appropriate model for the Dominican Republic. Cult Health Sex 2001;3(2):221-40; Kerrigan D, Moreno L, Rosario S, et al. The impact of two 100% condom use models in reducing HIV-related risk among female sex workers in the Dominican Republic. Unpublished paper. Horizons Program, 2002. Available: http://www.popcouncil.org/horizons/horizonspublications.html; Kerrigan D, Ellen JM, Moreno L, et al. Environmental-structural factors significantly associated with consistent condom use among female sex workers in the Dominican Republic. AIDS 2003;17(3):415-23.