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Development of an Intervention for Clients of Female Sex Workers

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

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Development of an Intervention for Clients of Female Sex Workers

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  1. Development of an Intervention for Clients of Female Sex Workers TL Patterson, S Goldenberg, S Semple, SA Strathdee University of California, San Diego

  2. 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)

  3. Worldwide estimate of number of male clients of FSWs In Millions Source: 78 national household surveys and other sources to estimate percentage of men who reported paying for sex in previous 12 months

  4. 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

  5. Study setting: Tijuana, Mexico MEXICO USA Source: CALTRANS • Emerging HIV epidemic: 1/116 adults are HIV+1 • Sex work: Draws local, U.S., international clients • Mobility: World’s busiest international land crossing 1. 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.

  6. Background • 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 Source: Wikipedia Commons, 2007 Source: Wikipedia Commons, 2009 • Harcourt C, Donovan B. The many faces of sex work. Sex Transm Infect 2005;81(3):201-6. • Rhodes T. Risk environments and drug harms: A social science for harm reduction approach. International Journal of Drug Policy 2009;20(3):193-201.

  7. 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

  8. Baseline Assessment Mujer Segura One 40-minute one-on-one Counseling Session Didactic Safer Sex One 40-minute one-on-one Counseling Sessions Six Month Assessment Study Design

  9. Mujer Segura Counseling Topics* *incorporating motivational interviewing (MI) and social cognitive theory

  10. Intervention Effect on FSWs’ Incident STIs at 6-month Follow-up RR = 1.66 p = .04

  11. Incidence of HIV Infectionamong FSWs 0

  12. 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?

  13. Identify risk group Gather community support (Risk group, local, state & federal officials) Conduct epidemiologic studies to determine if an individual intervention is merited Conduct qualitative study to understand the context of risk behavior Develop theory-based intervention with specific context and risk behaviors in mind and adapt to cultural context as needed Revise intervention with stakeholders Conduct implementation study to enhance dissemination of intervention to agencies and CBOs Conduct randomized controlled trial to determine intervention efficacy Pilot test materials and revise as needed Steps to developing a efficacious intervention for clients

  14. Source: Wikipedia Commons, 2007 Qual-Quant Study: Objectives and hypotheses To examine correlates of clients who meet FSWs in nightlife venues To investigate clients’ perspectives on venue-based risks and bridging

  15. Methods • Men recruited in Tijuana’s ZonaRoja, 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

  16. Methods: Study population and data sources

  17. 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) †Refers to past 4 months

  18. Table 1: Socio-demographic, behavioral, environmental and HIV/STIs among FSWs’ clients in Tijuana, 2008 †Refers to past 4 months; ***p<0.001, **p<0.01, *p<0.05; °IQR: Inter-quartile range

  19. 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)*** **p<0.001, **p<0.01, *p<0.05 Photo By: Oralia Loza

  20. 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

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

  22. What proportion of clients are potential bridgers? Percent of 383 clients with wives/steady partners Percent of 134 clients with wives/steady partners who report unprotected sex 134 (35%) 70 (52%)

  23. Social Cognitive Factors of Bridgers and Nonbridgers OR 7.75* OR 0.81 OR 0.21* OR 3.78* OR 2.17* Mean Score * P<0.05

  24. Factors Independently Associated with Bridging Behavior Among Male Clients With Wives or Partners (n = 134) * P<0.05

  25. 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)

  26. Factors Independently Associated with Bridging Behavior Among Male Clients With Wives or Partners (n = 134) 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….”

  27. 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. MICRO • Jaladorpeer education, condom distribution • Counseling and support for ciients • MACRO • Economic and social support for clients • HIV/STI prevention and testing, drug treatment services for clients Implications and suggested interventions SUGGESTED INTERVENTIONS DRIVERS OF HIV VULNERABILITY1 Root causes Proximal causes 1. HIV Risk Environment framework, adapted from Rhodes, 2009

  29. 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

  30. Hombres Seguro Counseling *incorporating motivational interviewing (MI) and social cognitive theory

  31. 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

  32. 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

  33. THANK YOU For more information please contact: Thomas L. Patterson Department of Psychiatry University of California San Diego Email: tpatterson@ucsd.edu

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