Condoms Count for HIV Prevention

Box7: Experiences with 100% Condom Use Programs

In response to increasing HIV and STI prevalence among female sex workers (FSWs) in Thailand, the government initiated the 100% Condom Use Program (CUP) in Ratchaburi province in 1989. The premise of the 100% CUP is to create an environment where condoms must be used in all sex establishments throughout a large geographic area, for all sexual encounters, 100% of the time.²⁵⁴ The intention of the program is to empower sex workers to practice a policy of “No Condom – No Sex” in all commercial acts. Success of the program has depended upon garnering the support of owners of sex establishments, as well as members from the health, law enforcement and local administrative sectors.²⁵⁵
 
100% CUP was scaled-up nationwide in Thailand and has been credited with averting over five million HIV infections.²⁵⁶ Building on the Thai model, seven other Asian countries have adapted and implemented versions of the 100% CUP. Cambodia initiated the program in 1998, and became the second country to scale-up nationwide in 2001, contributing to the near halving of HIV prevalence among brothel-based sex workers between 1998 and 2003.²⁵⁷ Following suit in 1999, the Philippines developed a 100% CUP program, reaching 17 sites by 2005, and is still expanding. In 2000, both China and Viet Nam began to implement 100% CUP. By 2006, the 100% CUP had reached ten of China’s 31 provinces and 21 of Viet Nam’s 64 provinces. Between 2001 and 2006 the 100% CUP was scaled-up in Myanmar to reach 152 of 324 townships. Data from the pilot sites show that condom use among sex workers increased from 61 percent in 2001 to 91 percent in 2002.²⁵⁸ Nationwide scale-up of 100% CUP is also currently underway in Mongolia and the Lao People’s Democratic Republic. The 100% CUP is also being adapted to settings outside of Asia, for example in Santo Domingo and Puerto Plata in the Dominican Republic.

While sex work remains illegal in all countries in Asia, the 100% CUP program has succeeded in collaborating with authorities to promote condom use in commercial sex as an important means of preventing the spread of HIV into the general population. Still, while advocates, including WHO and UNAIDS, tout the program’s ability to empower sex workers and improve their access to health care, some members of the sex worker community have criticized the program for being coercive to FSWs, rather than protective.²⁵⁹ Also, because programs target FSWs and not the male clients, the 100% CUP has not necessarily affected condom use in non-transactional partnerships. A 2005 study conducted among clients of sex workers in select brothels in Cambodia found that 58.3 percent of men surveyed reported having sex with multiple partners, including their wives. While they reported high condom use at last sex with a sex worker (97 percent), only 14 percent reported always using condoms with their girlfriends or wives.²⁶⁰

 

A qualitative study among sex workers in Mexico and the Dominican Republic found that participants considered condoms to be hygienic, offer disease protection, and provide a sense of security and peace of mind.²⁰⁵ A study conducted among 450 street sex workers in three settings in Ghana found that consistent condom use was associated with younger age of sex workers (24 years old or younger).²⁰⁶ This study in Ghana, and other studies conducted among sex workers in Kenya, Tanzania²⁰⁷ and Trinidad²⁰⁸ show that higher levels of education are also positively associated with consistent use of condoms by sex workers. However, insufficient condom knowledge can be a barrier to correct use of the method. In Benin, high breakage rates are associated with incorrect use among sex workers.²⁰⁹ Widespread exposure to violence also undermines the ability of sex workers to negotiate condom use and ensure the correct use of condoms [see Box 5: Gender-based Violence is a Barrier to Condom Use].

Generally, the more commercial the relationship, the easier it is for women to negotiate condom use, or the more willing men are to use condoms.²¹⁰ However, for many sex workers, the need for income outweighs the perceived consequences of risky sex. In a survey conducted among 200 female sex workers in southwestern China, economic deprivation was most frequently cited by respondents as their reason for acceptance of sex without condoms.²¹³ As studies have shown, clients are often willing to pay more for unprotected sex.²¹⁴

In some places, a lack of access to free condoms lowers the likelihood of use. Among 450 female street sex workers surveyed in Ghana, 50 percent reported using condoms consistently. However, fewer than 25 percent had access to condoms at no cost, and 69 percent said they would use condoms always if they had access to condoms free of charge.²¹⁵ A study in Nicaragua found that making no-cost condoms available in motels resulted in increased condom use during both commercial and non-commercial sex.²¹⁶

Innovative projects that incorporate sex workers’ perspectives and their meaningful involvement can improve the lives of women, their children and communities. For example, the Sonagachi Project in Kolkatta, India²¹⁷ has expanded over the past 15 years from a health promotion project to teach about AIDS and promote condom use and STI treatment, to a “multifaceted community effort to empower women not only to protect themselves from HIV but to fulfill their broader needs and aspirations.”²¹⁸ In South Africa, health-seeking behavior and condom use improved when services were made more accessible and “friendly”. The program provided a clinic for sex workers located in the same hotel where sex work took place, and providers were trained to be respectful and non-judgmental. ²¹⁹

"They treat us as diseases, no? Coming here only to distribute condoms, they don’t even look at our faces." Brazilian sex worker²²⁰

Clients of sex workers expose their other sexual partners to risk of HIV transmission, particularly regular partners and wives, with whom they are less likely to have protected sex. Although clients are often difficult to reach, they are important to reach with interventions, both to protect them and to prevent the spread of the disease in otherwise low-risk populations. A study conducted among clients of sex workers in Cambodia found that almost 40 percent of those interviewed reported having sex with women other than sex workers, but rarely used condoms with those partners.²²¹ Recently, a number of studies have documented high vulnerability to HIV infection among migrant workers in Asian countries.²²² A survey of 3,426 male and female migrants in Thailand found that among sexually active men, 25 percent reported visiting a sex worker in the past year. Male migrants reported high condom use with sex workers (79 percent reported always using condoms) but low condom use with regular partners (only 4 percent reported ever using condoms). Only three percent of women migrants reported ever using a condom with a regular partner. Despite their risky sexual practices, over 90 percent of both male and female migrants did not consider themselves at risk of HIV.²²³

Some interventions targeting male clients of sex workers have successfully increased condom use. For example, in Benin, one program established a confidential, free clinic specifically for men and male clients were targeted by male peer outreach workers at venues where sex work occurs.²²⁴ Condom use at last sex with a sex worker was 62 percent among men who were not exposed to the intervention, as opposed to 74 percent among men who were exposed to the intervention. During the period of the intervention, men’s consistent use of condoms with female sex workers increased from 55 percent to 86 percent and consistent condom use with casual partners increased from 25 percent to 65 percent, although these increases cannot be directly attributed to the intervention.²²⁵

Introducing a peer-mediated education and condom distribution program for male clients of sex workers in Senegal increased consistent condom use among regular, nonmarital partners from 45 to 90 percent. Surveys conducted among sex workers showed that the number of clients who “always” agreed to condom use rose from 30 percent to 54 percent.²²⁶ In India, an intervention targeted male clients with counseling on monogamy and condom use and provided free condoms every three months over a three-year period. Compared to baseline, consistent condom use was 2.8 times more likely at six months, and 3.6 times more likely at 18 months. By 24 months consistent condom use was 4.7 times more likely and monogamy increased from 61 percent at baseline to 84 percent.²²⁷

Please refer to the Appendix for end notes.