Acceptability of the female condom among sex workers in Thailand: results from a prospective study.

BACKGROUND: The female condom may provide women with the first female-controlled barrier method that is effective against sexually transmitted diseases, including HIV infection. GOAL: This study evaluated the acceptability of the female condom among sex workers in Thailand. STUDY DESIGN: Data on use and acceptability of the female condom were collected using a structured questionnaire during an 8-week follow-up. RESULTS: Analyses included 148 women who were still in follow-up at week 8. Sex workers used, on average, 2.8 female condoms per week. The overall satisfaction rate with the female condom was 68%, although, among users, 31% had difficulties in device insertion, 37% had pain from the inner ring, and 22% reported itching sensations. The main reason for using the female condom in the future was its perceived safety, and the main reason for not using it would be the client's refusal. CONCLUSION: Two-thirds of the sex workers were satisfied with the female condom. Difficulties at insertion, discomfort during use, and clients' attitude were potential obstacles to the use of the female condom in the future.

Protection against sexually transmitted diseases by granting sex workers in Thailand the choice of using the male or female condom: results from a randomized controlled trial.

BACKGROUND: The male condom is the most effective barrier method available for protection against sexually transmitted diseases (STDs), including HIV infection. There is an urgent need to develop and evaluate other prevention methods, such as the female condom. This study estimated the additional protection against STDs offered to sex workers by giving them the option of using the female condom when clients refused to use a male condom. METHODS: Sex establishments in four cities in Thailand were randomized into two study groups: one in which sex workers were instructed to use male condoms consistently (male condom group); and one in which sex workers had the option of using the female condom if clients refused or were not able to use male condoms (male/female condom group). Randomization was done by sex establishments, and not by individuals, to minimize sharing of female condoms across study groups. The proportion of unprotected sexual acts (defined as sexual acts in which condoms were not used, tore, or slipped in or out) and incidence rate of STDs (gonorrhoea, chlamydial infection, trichomoniasis and genital ulcer disease) were measured over a 24-week period and compared between the two study groups. FINDINGS: Results are available from 34 sex establishments (249 women) in the male/female condom group, and 37 sex establishments (255 women) in the male condom group. Condom use was very high in both groups (97.9 and 97.3 % of all sexual acts, respectively, P > 0.05). Male condom use was lower in the male/female condom group when compared with the male condom group (88.2 and 97.5%, respectively, P < 0.001). However, this reduction in male condom use was counterbalanced by the use of female condoms in 12.0% of all sexual acts in the male/female condom group, contributing to a 17% reduction in the proportion of unprotected sexual acts in this group when compared to the male condom group (5.9 versus 7.1%, respectively, P = 0.16). Female condom use was sustained over the entire study period. There was also a 24% reduction in the weighted geometric mean incidence rate of STDs in the sex establishments of the male/female condom group compared to the male condom group (2.81 versus 3.69 per 100 person-weeks, P = 0.18).

Changes in prostitution and the AIDS epidemic in Thailand.

The HIV/AIDS epidemic which broke out in Thailand 1988 was mainly caused by the widespread patronage of prostitutes. The Thai authorities responded with programmes which encouraged the use of condoms in commercial sex. These programmes were highly successful. However, prostitution has changed since the beginning of the epidemic, partly for economic and demographic reasons, but mainly because of the fear of AIDS. Fewer women practise prostitution, men patronize it less, and the price of commercial sex has risen. Prostitution is less likely to be practised in brothels and more likely to be practised in establishments like restaurants and bars. Moreover, as fewer native Thai women are willing to practise prostitution, foreign women are taking their place. In order to continue to control the epidemic, the authorities will have to adapt their programmes to the changing structure of commercial sex.

PIP: The Thai Government's HIV/AIDS Prevention and Control Program has promoted 100% condom use in commercial sex encounters. Condom use in sex establishments has risen from 14% of sex acts in 1989 to 94% in 1994, with concomitant declines in the prevalence of all sexually transmitted diseases. To maintain this trend of decline, Thai officials must attend to the changing structure of commercial sex work. These changes were analyzed through a review of official enumeration data sent to the Venereal Disease Division of the Ministry of Public Health in 1989-94. In January 1989, there were 86,201 female prostitutes working in 6095 commercial sex establishments (primarily brothels) for an average fee of US$10.60 per sex act. There was an inverse relationship between the price of sex and the level of HIV infection among sex workers in the province. By January 1994, there were only 66,035 prostitutes, centered primarily in indirect establishments such as massage parlors and restaurants and working for an average fee of $16.30. The decline in prostitution began after 1990, when the government launched its AIDS education campaign. It is presumed that, not only were women less willing to continue working as prostitutes because of fear of AIDS, fewer men were willing to patronize them. The decline in commercial sex activity also corresponded with improvements in the economy and expanded job opportunities. The recent shift from direct to indirect prostitution, where condom use is lower and beyond the control of authorities, is potentially problematic, however. Another concern is the recent influx into commercial sex work in Thailand of women from Myanmar who are hard for authorities to identify, counsel, and treat.

Promising results. Thailand.

PIP: This article describes the Thailand Ministry of Health's program for promotion of condom use. Since 1984, findings indicate that AIDS has been a leading public health problem that is spread through heterosexual intercourse. Since 1989, the government has conducted IEC programs to increase knowledge and change attitudes and practices for controlling HIV infections, AIDS, and other sexually transmitted diseases (STDs). A variety of institutions dispense condoms. Condom use was promoted over a 25-year period. The 100% condom program, implemented in 1989, has been successful in promotion of condoms among sex workers and clients. IEC to prevent AIDS has been operating since 1984. Messages focus on prevention of sexually transmitted HIV infections and correct use of condoms. Family planning programs over the past 30 years have supplied condoms free of charge. Condoms are available for sale through pharmacies and convenience stores. Health service facilities also supply condoms. The 100% condom program began as a pilot in Ratchaburi province. All owners of sex establishments cooperated. The program was initiated jointly by government officials and owners of sex establishments. Owners instructed sex workers about use of condoms in all sexual encounters. Penalties were imposed on owners for noncompliance. Condom use increased gradually and STDs declined. In 1991, the program was expanded nationwide. In 1992, condom quality control measures were instituted. Water soluble lubricants for condoms were added to prevent breakage and increase customer satisfaction. This program needs to be expanded to other sectors of the population.^ieng

Prevention as policy: how Thailand reduced STD and HIV transmission.

PIP: In 1989, in response to growing HIV seroprevalences among intravenous drug users and low-fee commercial sex workers in northern Chiang Mai, the Government of Thailand launched a massive expansion of its HIV/AIDS Prevention and Control Program. The most ambitious, innovative aspect of this effort was the 100% Condom Program established in 1991 to enforce universal condom use in all commercial sex establishments. Every sex worker is presented with a box of 100 condoms or more when she reports for a regular sexually transmitted disease (STD) checkup at a government clinic. When health officials visit commercial sex establishments, they take along boxes of condoms. Strong pressure, often from the police, is placed on brothel owners who fail to support the campaign. By 1994, over 90% of commercial sex acts were protected by condoms and the number of men presenting to government clinics for STD treatment dropped by 90% from 1989 to 1995. Moreover, the number of commercial sex workers has declined by 25% since 1989. Models of the AIDS epidemic indicate that Thai health authorities should continue to focus on commercial sex for the control of HIV.^ieng

Lubrication use in condom promotion among commercial sex workers and their clients in Ratchaburi, Thailand.

Condom promotion has been intensified in Thailand to prevent the spread of HIV. A water soluble lubricant (WSL) could be used to alleviate many unpleasant side effects of frequent condom use experienced by sex workers and their clients. This study was conducted to determine the efficacy of WSL use in preventing the side effects of condom use including condom breakage, and to assess the acceptance of WSLs within the sex-worker population. The results of this study showed that 83 (111) of the 134 sex workers reported use of the WSL provided during the study period and more than 95 per cent (106) expressed interest in employing the WSL regularly, saying that WSLs reduce unpleasant side-effects relating to frequent condom use. Also 70 per cent of them reported that the majority of their clients found using the WSL made condom use more enjoyable. A follow-up study showed that 57 per cent of the respondents were still using a WSL on a regular basis and all of them felt it reduced condom breakage. Therefore, WSL use should be an acceptable and useful method for alleviating problems associated with regular use of condoms within the sex-worker population. In addition, there is evidence that WSLs can reduce the incidence of condom breakage. Thus, WSLs could be valuable tools in condom promotion for AIDS control within this high risk population and their clients.

PIP: A study was conducted in Ratchaburi, Thailand, to determine if water soluble lubricants (WSLs) could reduce the problems associated with frequent condom use among female commercial sex workers (CSWs). 134 CSWs were recruited during March 1990 for participation from 10 different sex entertainment establishments in the city. All establishments were promoting 100% condom use and had high numbers of male clients. The participants were of mean age 22 years in the range of 14-34, had been working as prostitutes for a mean period of 2.2 years, and had an average of 3.4 clients per day. All reported using condoms at least sometimes, but only 55% reported 100% condom use. Disease prevention, cleanliness, and birth control were cited as reasons for condom use. 83% expressed their discontent with regular condom use due to the longer time required for any given client to ejaculate, discomfort or pain, and condom breakage. 50% had never used WSLs before the study. The women were given K-Y Jelly packets each containing 2.7 g of lubricant gel. One week later, 111 of the original 134 participants completed a second round of interviews. They reported an average of two clients per day during the study period and used WSLs with 68% of them. Approximately 95% expressed interest in using WSLs on a regular basis, explaining that WSLs reduced the time clients took to ejaculate, reduced vaginal pain and discomfort, and reduced condom breakage. More than 70% of the women reported that the majority of their clients found using WSLs made condom use more enjoyable. 58 of the 111 CSWs from the second round of interviews were followed two months later. At that time, almost 57% reported using WSLs on a regular basis, with 94% obtaining their WSLs from local venereal disease clinics. WSLs were used in 46% of sexual episodes. Of the 33 participants who reported using WSLs regularly, all agreed that WSLs reduced the incidence of condom breakage.

Evolution of the response to AIDS in Thailand.

PIP: The first case of AIDS was reported in Thailand in 1984, precipitating the cumulative total of 5990 cases reported in 1994; 3959 of these cases were detected in 1993. More than 600,000 people are estimated to be infected with HIV in the country, yet asymptomatic. Heterosexual intercourse is the most common mode of HIV transmission. At first, the Thai government denied that AIDS was a serious problem. It has since, however, implemented one of the most aggressive, comprehensive HIV/AIDS control programs in the world. The government provided basic public education through some government STD clinics over the period 1983-87 with focus upon determining and tracking the extent to which HIV and AIDS had pervaded society. People perceived to be at high risk of infection were warned, reported AIDS cases were investigated by the Ministry of Health, and serosurveillance was established among groups of people whose behavior put them at high risk of acquiring HIV. An AIDS committee was established in 1985 leading to the approval and launching of an AIDS prevention and control plan over the period 1987-91 of HIV serosurveillance among many target groups, AIDS education activities for the public, and health personnel training to be carried out independently by different units of the government located mostly within the health sector. Operations were centralized under the Center for Prevention and Control of AIDS established in October 1987, blood donations were universally tested, and the overall government budget for AIDS increased from US$200,000 in 1988 to $45 million in 1993 spread among ministries beyond that responsible for public health. AIDS prevention policies are described on condom availability, medical care and counseling, and confidentiality and antidiscrimination, as well as lessons learned and major achievements.^ieng

Impact of Thailand's HIV-control programme as indicated by the decline of sexually transmitted diseases.

The Thai government began an HIV-control programme in 1989. The programme had the following parts: the government bought and distributed sufficient condoms to protect much of the commercial sex in the country; sanctions were brought against commercial sex establishments where condoms were not used consistently; and a media campaign bluntly advised men to use condoms with prostitutes. Between 1989 and 1993 the use of condoms in commercial sex in Thailand increased from 14 to 94%, according to surveys of prostitutes, and the number of cases of the five major sexually transmitted diseases declined by 79% in men. We estimate that sex acts with prostitutes where there was a risk of HIV transmission declined from about 2.6% in June, 1989, to about 1.6% in June, 1993. If condom use in commercial sex stays high, future cohorts of young men and women may experience lower HIV incidence rates than those of the recent past. However, although condom use is high, there are many more infected prostitutes than before and many infected men who will pass HIV to their wives.

Incidence of sexually transmitted diseases among massage parlour employees in Bangkok, Thailand.

The results of a study of sexually transmitted disease (STD) incidence and related risk factors for STDs among uninfected women at high risk of contracting STD infection in Bangkok are reported. Comprising the control arm of a randomized controlled trial of a vaginal contraceptive sponge and STD incidence, 163 women aged 18 or older were recruited from 4 massage parlours and followed for evidence of new infections over a 6-week period or until cervical infection occurred. Gynaecological examinations were performed and endocervical specimens were obtained at weekly intervals, at which time women returned coital logs recording their number of sexual partners. There were 76.5 new STD infections per 100 woman-months, including 31.7 with gonorrhoea, 43.1 with chlamydia, 1.8 of trichomoniasis and 3.5 of candidiasis. None of the risk factors examined were good predictors of STD infection in this population, which may be related to the restricted admission criteria in the study.

The contraceptive sponge's protection against Chlamydia trachomatis and Neisseria gonorrhoeae.

To investigate the effect of the contraceptive sponge on the incidence of sexually transmitted diseases, we conducted a clinical trial among a high-risk population of women in Bangkok, Thailand. Two hundred fifty-five women were randomly assigned either to use the sponge or not and were evaluated weekly for gonorrhea and chlamydial infection. After adjustment by logistic regression for potentially confounding factors, women using the sponge were less likely to have contracted chlamydial infection (odds ratio [OR], 0.6; 90% confidence interval [CI], 0.4-1.0) and gonorrhea (OR, 0.9; CI, 0.6-1.3) as compared with women not using the sponge. These estimates probably underestimate the degree of protection because some exposure was misclassified in this pilot phase of the study. These results are consistent with other studies indicating that spermicides protect against gonorrhea and also demonstrating protection against an organism of even greater public health concern, Chlamydia trachomatis.

Effect of the contraceptive sponge on chlamydial infection, gonorrhea, and candidiasis. A comparative clinical trial.

To investigate the effect of the nonoxynol 9-impregnated contraceptive sponge on the incidence of chlamydial infection, gonorrhea, and candidiasis, we conducted a randomized comparative study among high-risk women in Bangkok, Thailand. The first (parallel) portion of the study covered 434 woman-weeks among sponge users and 494 woman-weeks among nonusers. As compared with women not using the sponge, sponge users were found to be less likely to become infected with chlamydia (relative rate, 0.67; 95% confidence interval, 0.42 to 1.07) and gonorrhea (relative rate, 0.31 [0.16 to 0.60]) but more likely to become infected with Candida (relative rate, 2.76 [0.96 to 7.98]). Women who continued in the study were crossed over to the alternate group, with former nonusers starting to employ the sponge and vice versa. The results of this second phase were similar to those of the larger parallel study. Overall, these results suggest that women using the sponge are protected against the two most common sexually transmitted pathogens, which are also those with the most serious health consequences. However, women using the sponge should be advised they may have an increased likelihood of a vaginal infection with Candida.

Prevalence of HTLV-III/LAV antibody in selected populations in Thailand.

Antibody to the human T-lymphotropic virus, type III/lymphadenopathy-associated virus (HTLV-III/LAV) by ELISA test was detected in one (1%) of 101 male homosexual prostitutes (confidence limit 95%:0.03-5.4%, in two (2%) of 100 thalassemia patients, and in none (C.L. 95%:0-3.6%) of 100 female prostitutes, 99 parenteral drug abusers, 100 male VD patients, 100 consecutive blood donors in serum collected from February through June 1985. Serum from the positive homosexual subject was strongly positive on repeated ELISA testing, and was also positive by Western Blot test. The two thalassemia patients, who were repeatedly weakly-positive by ELISA, were negative by Western Blot test and presumed to be false positive reactors. Prevalence of HTLV-III/LAV virus in sexually-active homosexuals in Thailand in 1985 appears to be similar to the 1% rate among homosexuals in San Francisco in 1978 at the start of the AIDS epidemic there.