Targeting populations at increased infection risk: condom promotion remains an important HIV prevention measure.
Sex work in non-brothel establishments such as restaurants, bars, and massage parlors is so common in many settings that a variety of interventions are attempting to reach these populations with condom use messages. (Notably, while it is recognized that many social, cultural, and economic conditions foster commercial sex work, FHI and similar organizations are unable to eliminate these conditions. Rather, FHI intervenes to help such women protect themselves from acquiring or transmitting HIV/STIs and prevent unplanned pregnancy.)
A Dominican Republic condom promotion intervention highlighted in this issue (see article, page 9) involves sex workers employed in both brothel and non-brothel establishments. Meanwhile, FHI is conducting an intervention targeting female employees of two Asian-based breweries who supplement their income with sex work.
"Female beer promoters, who serve beer to customers in restaurants, are paid little and are under constant pressure to either meet sales targets or lose income," says Michael Merrigan, senior program officer in FHI's Cambodia office. "They are in close contact with customers, and many supplement their meager income by having sex with customers after hours." To help these women protect themselves against HIV/STIs, FHI offers a comprehensive prevention approach that includes peer education, building relationships with establishment owners to facilitate women's access to HIV/STI education and services, STI services delivered at beer promoters' homes, as well as condom promotion.
FHI's work with female beer promoters is part of a larger program that regularly targets both brothel-based and non-brothel-based sex workers in Cambodia for HIV/STI outreach education. FHI's HIV/STI prevention and care activities with non-brothel-based sex workers also focus on women working in such establishments associated with commercial sex as karaoke beer gardens, massage parlors, and guest houses/hotels. FHI-supported interventions include outreach and peer education to provide information and behavior change messages about HIV/STI prevention, provision of and referral to STI treatment services, and condom promotion. And, as more sex workers have learned their HIV status, FHI has begun to address care, treatment, and support issues for this group.
GREATER EMPHASIS ON MEN
Use of a wide array of HIV/STI prevention strategies holds the most promise for reducing the spread of these infections. FHI both promotes and implements what it calls an "ABC to Z" model: abstinence, be faithful to one partner, or--if "A" or "B" cannot be achieved--use condoms. These three strategies can be further complemented by a number of other effective HIV prevention approaches; that is, the "to Z" component of the "ABC to Z" model. (See article, page 3.) Although condom use is an important element of this comprehensive approach, men often express a dislike for condoms and are particularly likely to abandon condom use with regular partners, whom they assume are not infected with HIV/STIs. In Thailand, young men are decreasing their patronage of brothel-based sex establishments, (1) but they are increasingly engaging in unprotected sexual relationships with female peers. (2) A 2001 study found that two-thirds of 5,646 young men inducted into the Royal Thai Army in May 1999 had sex with a girlfriend within the past year, but just 13 percent used a condom. (3) Research also indicates that some young men continue to buy sex in informal venues while concurrently having unprotected sex with female peers. (4) This puts their presumably low-risk, regular partners at high risk of infection.
The vulnerability to HIV infection of presumably low-risk individuals is also illustrated in a modeling exercise, conducted in Cambodia with assistance from FHI. In 2002, the Cambodia Working Group on HIV/AIDS Projection estimated that almost half of new infections in the country that year were transmitted between husbands and wives. (5)
Given that men often make the final decision on condom use in sexual relations, attempting to increase their condom use is a challenge that reproductive health workers continue to address.
In Harare, Zimbabwe, FHI researchers and in-country collaborators began to explore in 2002 whether partners of 344 women (who had been through a two-month condom promotion intervention) felt more comfortable learning about condom use in all-male group sessions or in couple sessions with their regular partners. Preliminary results from this randomized trial show that a similar and unexpectedly high proportion of men (about 40 percent) attended condom promotion sessions when invited, regardless of type of session.
"That level of male involvement is much higher than expected and is encouraging in terms of getting males involved in condom promotion activities via their regular partners," says Dr. Markus Steiner, an FHI senior epidemiologist who helped design the study. "We think our results show that, in a country like Zimbabwe where there is a very good existing family planning infrastructure, it is possible to get men more involved in a family planning setting."
Meanwhile, a review of operations research in 13 countries found that having men promote condoms through community-based distribution (CBD) programs can increase not only the total number of condoms that programs distribute, but also the number dispensed to male clients. (6) The report highlighted research in Peru that found that male CBD workers with the Promocion de Labores Educativas y Asistenciales en Favor de la Salud (PROFAMILIA) CBD program in Lima sold twice as many condoms per month as did female CBD workers: a median of 49 condoms and 24 condoms per month, respectively. The Peruvian study found similar performance patterns among workers in the Centro NorPeruano de Capacitacion y Promocion Familiar (CENPROF) CBD program in Trujillo, (7) as did a 1995 study among CBD volunteers in the Kilifi district of Coast Province, Kenya. Fifteen male CBD volunteers in the Kilifi district each distributed approximately 9,550 condoms during the 18-month study period, while 15 female CBD volunteers in the same district each distributed approximately 3,523 condoms. (8) Both studies adjusted for other factors that could influence worker performance, including education, occupation, marital status, training, length of time in the program, and CBD post location.
Having men promote condoms through CBD programs may require adjustments in attitudes, recruitment methods, and training schedules. The Peruvian study found that female program managers never fully accepted men in the CBD program and that, in spite of male CBD workers' high productivity, female managers continued to have doubts about the men's work. "Men have less free time to do the work," one manager observed. Another commented, "Men produce less." Such attitudes may have contributed to the fact that female CBD workers replaced male counterparts who left the program. (9) Research in Tanzania found that men in some communities initially had reservations about male CBD workers distributing condoms and other contraceptives to their wives, although they changed their views after becoming more familiar with the program. (10)
While recruiting men into CBD programs can be difficult, research has found that CBD training curricula do not need to be markedly altered to accommodate male workers. (11) Only the timing of sessions may need to be changed. In Peru, both the PROFAMILIA and CENPROF CBD programs scheduled training on weekends to accommodate men's work schedules. (12)
OFFERING A CHOICE
In the effort to encourage condom use among men, researchers are studying whether offering them a choice of male condoms increases rates of use and decreases STI rates. FHI researchers are conducting randomized controlled trials in Jamaica, Ghana, Kenya, and South Africa to explore this idea. (13)
In Kingston, Jamaica, FHI is studying condom preferences of 1,000 men attending the capital's largest STI clinic for treatment of urethral discharge. Half of the men will be offered only the standard condoms distributed at the clinic. The other group will be offered Rough Rider condoms, designed with ribbed "pleasure bumps"; Inspiral condoms, which have a loose-fitting shape to enhance sensation; standard condoms issued by the U.S. Agency for International Development (USAID); and standard clinic condoms. At study enrollment, the men are being screened and treated for gonorrhea, trichomoniasis, and chlamydial infection. Screening for these STIs will continue at regular intervals during this six-month study. Structured individual interviews are being conducted at each study visit to learn about condom use and selection. Data collection is expected to be complete in July 2004.
"If we find that providing a choice of condoms has no impact on self-reported use and STI incidence, then programs should just provide the least expensive condom available and not spend resources providing slightly more expensive condoms with fancy packaging or features to enhance pleasure, such as ribs or a looser fit," says FHI's Dr. Steiner, the study's principal investigator. "However, if we find that choice increases condom use and decreases STI rates, then providing a choice is an intervention that could be easily replicated elsewhere."
FHI's condom choice trials in Ghana, Kenya, and South Africa are similar to the trial in Jamaica, except that only self-reported condom use data are being collected. In all three sites, men assigned to a "choice" group are being given their selection of four condoms: Rough Rider, Inspiral, USAID-issued, or each country's socially marketed condom. Men in a "no-choice" group are being offered only the USAID condom.
The studies in Ghana and South Africa are yielding interesting early findings. FHI researchers have noted that study participants are selecting the Rough Rider as their first choice and the Inspiral and the socially marketed condoms as their second choices. "The interesting thing is that in both countries, the socially marketed condoms are essentially the same as the USAID condoms--they are just packaged differently," says Carol Joanis, an FHI associate director and the principal investigator of the studies in Ghana, Kenya, and South Africa. Joanis plans to conduct focus groups with study participants to find out reasons for their condom selections.
"We need to know why participants like particular condoms," Joanis says. "Do they prefer condom attributes, like the bumps and ridges? Are they attracted to a condom based on the way it was promoted? Or, do they simply like the color of the packaging?"
(1.) Nelson KE, Eiumtrakol S, Celentano DD, et al. HIV infection in young men in northern Thailand, 1991-1998: increasing role of injection drug use. J Acquir Immune Defic Syndr 2002;29(1):62-68; Nelson KE, Celentano DD, Eiumtrakol S, et al. Changes in sexual behavior and a decline in HIV infection among young men in Thailand. N Engl J Med 1996; 335(5):297-303.
(2.) VanLandingham M, Trujillo L. Recent changes in heterosexual attitudes, norms and behaviors among unmarried Thai men: a qualitative analysis. Int Fam Plann Perspect 2002; 28(1):6-15; Saengdidtha B, Ungchusak K. Sexual behaviours and sexually transmitted diseases among young Thai men in 1999. Venereology 2001;14(4):157-59.
(5.) The Cambodia Working Group on HIV/AIDS Projection. Projections for HIV/AIDS in Cambodia: 2000-2010. Phnom Penh, Cambodia: National Center for HIV/AIDS, Dermatology and STDs, 2002.
(6.) Population Council. Program Brief No. 2. Using Men as Community-Based Distributors of Condoms. Washington, DC: Frontiers in Reproductive Health, Population Council, 2002.
(7.) Foreit JR, Garate MR, Brazzoduro A, et al. A comparison of the performance of male and female CBD distributors in Peru. Stud Fam Plann 1992;23(1):58-62; Population Council.
(8.) Family Planning Association of Kenya and Population Council/Africa OR/TA Project. Increasing Male Involvement in the Family Planning Association of Kenya (FPAK) Family Planning Program. Nairobi, Kenya: Population Council, 1995.
(10.) Chege J, Rutenberg N, Janowitz B, et al. Factors Affecting the Outputs and Costs of Community-Based Distribution of Family Planning Services in Tanzania. Nairobi, Kenya: Population Council, 1998; Population Council.
(11.) Family Planning Association of Kenya and Population Council/Africa OR/TA Project; Foreit.
(13.) Steiner M. Update--condom choice initiative. Annual meeting of the FHI Technical Advisory Committee, Contraceptive Technology and Family Planning Research, Chapel Hill, NC, May 2, 2002.