Development of an Intervention for Clients of Female Sex Workers

TL Patterson, S Goldenberg,

S Semple, SA Strathdee University of California, San Diego

Clients of Female Sex Workers (FSWs)

• Sex work is driven by demand– 3 million FSWs worldwide, and growing

•  Most studies focus on FSWs to the exclusion of male clients

• Clients of FSWs:– Risk becoming infected with STI

themselves– Infecting FSW with STI– Bridge to other sex partners (e.g. wives,

girlfriends, MSM)

Worldwide estimate of number of male clients of FSWs

Source: 78 national household surveys and other sources to estimate percentage of men who reported paying for sex in previous 12 months

In M

illio

ns

Sex Work in Tijuana, Mexico

• Sex work is regulated in many Mexican border cities, such as Tijuana

• ~ 9000 FSWs in Tijuana attract clients from Mexico and US

• Prevalence of HIV is 6% and rising among FSWs in Tijuana

• HIV prevalence 5% among

FSWs’ clients

Study setting: Tijuana, Mexico

Emerging HIV epidemic: 1/116 adults are HIV+1

Sex work: Draws local, U.S., international clients

Mobility: World’s busiest international land crossing

51. Iñiguez-Stevens, E., et al. (2009). [Estimating the 2006 prevalence of HIV by gender and risk groups in Tijuana, Mexico] [article in Spanish]. Gaceta Médica de México,145(3):189–195.

Source: CALTRANS

USA

MEXICO

• Impact of sex work depends on form, context, location1

• “Risk environment” 2

– Economic - incentives for risky sex– Policy - sex work regulation, condom

availability– Physical – venues– Social - interactions

with clients,

alcohol and drug use

6

Background

1. Harcourt C, Donovan B. The many faces of sex work. Sex Transm Infect 2005;81(3):201-6.2. Rhodes T. Risk environments and drug harms: A social science for harm reduction approach. International Journal of Drug Policy

2009;20(3):193-201.

Source: Wikipedia Commons, 2009

Source: Wikipedia Commons, 2007

Where did our work begin:Safer sex intervention for FSWs

• Study aim– Test a brief theory based

intervention designed for Mexican FSWs in Tijuana and Cd. Juarez

Source: Oralia Loza

Baseline Assessment

Mujer Segura

One 40-minute one-on-one Counseling Session

Six Month Assessment

Didactic Safer Sex

One 40-minute one-on-one Counseling Sessions

Study Design

Mujer Segura Counseling Topics*

Topic Description

Context of Unsafe Sex

Develop insights into motivations/triggers of unsafe sex. Set plan and goals for safer sex

Condom Use MI and skill-building to induce behavior change. Match counseling to individual’s stage of change

Negotiation of Safer Sex

MI and skill-building to teach negotiation skills to move participants into action

*incorporating motivational interviewing (MI) and social cognitive theory

7.7%

12.8%

0.0%

4.0%

8.0%

12.0%

16.0%

Any new STI

Pe

rce

nta

ge

of

Pa

rtic

ipa

nts

Intervention Control

RR = 1.66

p = .04

Intervention Effect on FSWs’ Incident STIs at 6-month

Follow-up

Incidence of HIV Infectionamong FSWs

Incident HIV

0

0.5

1

1.5

2

2.5

Intervention Control

Condition

Inc

ide

nc

e p

er

pe

rso

n

ye

ar

0

Conclusions• FSWs in the intervention arm significantly:

– reduced incident STIs/HIV– Increased the percent of time they used condoms with

clients

• But … this intervention puts the burden of safer sex on the sex worker when the clients are a significant part of the problem

• How do we develop an intervention for clients?

Pilot test materials and revise as needed

Conduct randomized controlled trial to

determine intervention efficacy

Conduct implementation study to enhance dissemination of

intervention to agencies and CBOs

Identify risk group Gather community support(Risk group, local, state & federal officials)

Conduct epidemiologic studies to determine if an individual

intervention is merited

Develop theory-based intervention with specific context and risk behaviors in mind and adapt to cultural context as

needed

Conduct qualitative study to understand the context of risk behavior

Revise intervention with stakeholders

Steps to developing a efficacious intervention for clients

14

Qual-Quant Study: Objectives and hypotheses

(1) To examine correlates of clients who meet FSWs in nightlife venues

(2) To investigate clients’ perspectives on venue-based risks and bridging

Source: Wikipedia Commons, 2007

Methods• Men recruited in Tijuana’s Zona Roja, 2008-09.

– paid/traded for sex with FSWs in previous 4 months – aged ≥18 years – from the U.S. or Mexico

• Participants underwent interviews and rapid testing for HIV and STIs.

• Recruited through jaladores• (touts) and street outreach

Methods: Study population and data sources

16

In-depth qualitative interviews (n=30)

Purposive sub-sample of male clients

Perceived HIV/STI risk

Condom use

Sex purchasing experiences

Social and structural factors (e.g., venues, paying more for unprotected sex)

Quantitative interviews(n=400)

Males≥ 18 who paid/traded for sex with a FSW in Tijuana, past 4 months

Surveys• Demographics, sexual behavior, substance use• Venues

Laboratory testing• HIV, Syphilis, Chlamydia, Gonorrhea

Methods: Variables• Dependent

– Met FSW in nightlife venue (i.e. bar, cantina, nightclub, or strip club)† (yes vs. no)

• Independent– Socio-demographics– Sexual behavior and substance use – Physical environment (lives in US vs. Mexico)– Social environment (e.g., client and FSW

alcohol use during sex†)– Policy environment (e.g., non-availability of

condoms as reason for unprotected sex) 17

†Refers to past 4 months

Table 1: Socio-demographic, behavioral, environmental and HIV/STIs among FSWs’ clients in Tijuana, 2008

Measure % who met FSW in nightlife venue (n=301)

% who did not meet FSW in nightlife venue (n=98)

Socio-demographics

Hispanic/Latino 80.1 78.6

Speaks English 81.7 77.6

Lives in Mexico 52.8 52.0

Years of education (median, IQR) 12 (9, 12)** 10 (7, 12)

Sexual behavior and substance use

Had unprotected sex with FSW† 55.1*** 35.1

Has ≥ 5 drinks when drinking 44.9*** 17.3

Risk environment

Offered extra money for unprotected sex 19.6** 8.2

Amount paid for sex in dollars (mean, IQR) 36.7 (20, 40)** 26.1 (20, 30)

Self reported STI† 19.4* 9.4 18

†Refers to past 4 months; ***p<0.001, **p<0.01, *p<0.05; °IQR: Inter-quartile range

Correlates of meeting FSWs in nightlife venues

• Ever offered FSW in Tijuana more money for unprotected sex– AOR: 2.65 (1.19, 5.93)**

• Binge drinking– AOR: 4.13 (2.30, 7.42)***

19

**p<0.001, **p<0.01, *p<0.05

Photo By: Oralia Loza

Qualitative Themes: venue-based HIV risks

• Clients described nightlife venues as high-risk:– Heavy alcohol consumption impairs judgment

• Courting rituals in nightlife venues• Binges, letting go of inhibitions

– Monetary incentives for unprotected sex in bars• Pressure from establishments to earn $

– Less enforcement of sex work regulations than on the street• Bar-based sex work less visible 20

Example: less enforcement of nightlife-based sex work

“I prefer the ones [girls] on the street who are controlled with the paperwork than the ones who aren’t… The girls on the strip there [the Callejon] constantly get the health workers asking for their cards [sex work permits]. You know, they got to be checked [tested for STIs/HIV], or they can’t work. So I would prefer to mess with those girls….”

21

Source http://www.ericrench.com/MEXICO/TIJUANA/NORTE/INTRO/index.htm 2011

What proportion of clients are potential bridgers?

Percent of 383 clients with wives/steady partners

134 (35%)

70 (52%)

Percent of 134 clients with wives/steady partners who

report unprotected sex

Social Cognitive Factors of Bridgers and Nonbridgers

OR3.78*

OR2.17*

OR7.75*

OR0.81

OR0.21*

Me

an

Sc

ore

* P<0.05

Factors Independently Associated with Bridging Behavior Among Male Clients

With Wives or Partners (n = 134)

Characteristic or Behavior

Adj OR 95% CI

Used drugs during sex with FSW, past 4 months

3.39* (1.40 – 8.23)

Ever offered FSW extra money to have sex without a condom

24.52* (3.08 – 195.4)

Sexual sensation seeking scale 4.28* (1.41 – 13.02)

* P<0.05

Factors Independently Associated with Bridging Behavior Among Male Clients

With Wives or Partners (n = 134)

Characteristic or Behavior

Adj OR 95% CI

Used drugs during sex with FSW, past 4 months

3.39* (1.40 – 8.23)

Ever offered FSW extra money to have sex without a condom

24.52* (3.08 – 195.4)

Sexual sensation seeking scale 4.28* (1.41 – 13.02)

Client (age 26): “Once they get the drugs in them, then they don’t give a damn about a condom. It’s all about the high and the money. The condom is not important.”

Factors Independently Associated with Bridging Behavior Among Male Clients

With Wives or Partners (n = 134)

Characteristic or Behavior

Adj OR 95% CI

Used drugs during sex with FSW, past 4 months

3.39* (1.40 – 8.23)

Ever offered FSW extra money to have sex without a condom

24.52* (3.08 – 195.4)

Sexual sensation seeking scale 4.28* (1.41 – 13.02)

Client age 23:“I am a risk junkie. It creates more excitement for me, makes it more euphoric. I figured that out about myself. The more prohibited things are, the more exciting it makes me feel….”

Conclusions• Clients are at risk of bridging HIV/STIs to FSWs and the

general population.

• Half of clients who have unprotected sex with a regular sex partner also report unprotected sex with FSWs

• Greatest risks posed by venues where:

– clients have more control– alcohol/drugs are used, and– high numbers of client are encouraged

• Cannot generalize findings from any one culture to another, but in this context, implications for interventions indicate: – Modifiable behaviors: drug and alcohol use– More difficult to modify: sensation seeking, misogyny

28

MACRO

Poverty, economic desperation

Immigration and deportation policies

Harm reduction policies

Incarceration

Access to health and social services

MICRO

Local social norms

Social isolation

Economic roles

Social networks

Unprotected sex

Substance use

HIV

Root causes

Proximal causes

Implications and suggested interventions

MACRO• Economic and social

support for clients• HIV/STI prevention and

testing, drug treatment services for clients

1. HIV Risk Environment framework, adapted from Rhodes, 2009

MICRO• Jalador peer education,

condom distribution• Counseling and support

for ciients

SUGGESTED INTERVENTIONSDRIVERS OF HIV VULNERABILITY1

Where are we now?

• Testing individual intervention for clients in Tijuana– Study design 200 receive Hombres Seguro,

200 didactic presentation; 6 and 12-mo FU• Implementation study of Mujer Segura in

12 cities in Mexico

Hombres Seguro Counseling

*incorporating motivational interviewing (MI) and social cognitive theory

STEP 1: Determine readiness for change, and build motivation for change

STEP 2: Explore participant’s attitudes toward condoms and unsafe sex

STEP 3: Assess high-risk situations, explore triggers of unsafe sex, and discuss coping with cravings and urges

STEP 4: Explore drug/alcohol use as triggers of sexual risk behaviors with FSWs: discuss harm reduction strategies

STEP 5 Identify barriers to unsafe sex with FSWs: make plans to overcome barriers

STEP 6: Condom skill-building exercise

STEP 7: Communication and safer sex practices & evaluation of roleplay

Collaboration• México collaborators M Gallardo, R. Lozada, C. Magis

• U.S. collaborators, A. Robertson

• Study Staff and Participants

• PREVENCASA A. C

• COMUSIDA A.C

• ISESALUD/CAPASITS

• Asociación de Bares and Hoteles

• Binational Committee on Human Rights

• Municipal Medical Services

• Volunteer bartenders, security guards

Acknowledgements

• UCSD CFAR International Pilot Grant to R. Lozada (UCSD CFAR is funded by NIH P30 AI036214)

• NIDA Grants: R01 DA029008;R01 DA023877-S1

• San Diego County Public Health Laboratory

Source: Shira Goldenberg

THANK YOU

For more information please contact:

Thomas L. Patterson

Department of Psychiatry

University of California San Diego

Email: tpatterson@ucsd.edu