Research report of comprehensive intervention for HIV/AIDS prevention in urban Beijing
http://www.100md.com
《中华医药杂志》英文版 2006年第3期
Correspondence to QIAO Lei,Technology Department,WHO Collaborating Center for Urban Health Development,Beijing 100007,China
TEL:+86-10-64032562,E-mail:qiaolei@hotmail.com
[Abstract]ObjectiveTo implement the WHO recommended strategy 100% condom use programme(CUP) in entertainment establishments(EE) in the Dongcheng District,Beijing,China. MethodsAdopting WHO recommended 100% CUP strategy and start with training of EE owners and managers/madams on the concept of safer sex and the rule of “ no condom,no sex” during commercial sex business in order for reduction of HIV risk among sex workers and prevention of HIV spread from sex workers and their clients to general population. The EE owners were required to educate sex workers in their places whenever on arrival of new comers the notion of 100% use of condoms for HIV/AIDS prevention. Two assessment supervision and one extra evaluation were arranged in 3 months after launching. Results86% of the sex workers and 100% of the EE owners accepted the idea of “no condoms, no sex service”. 80% of the sex workers used condoms in the last commercial sex with male clients. Compared with 2005, 10% more sex workers became aware of HIV/ADIS-related knowledge. ConclusionsIn order to realize the set objectives of ensuring all sex workers of using condoms in sex services, the project team must go on regular supervision visit to the establishments, especially accompanying with police officer and promote social marketing strategy to ensure condom supply then make the 100% CUP a routine and sustainable practice in all EE in the Dongcheng District.
[Key words]HIV/AIDS prevention; 100% condom use programme; entertainment establishments;sex worker;condoms
INTRODUCTION
To promote intervention of HIV/AIDS among high-risk group and explore most effective manners and operation models in the Dongcheng District,Beijing,China, we start to implement the “100% condom use programme (100% CUP) ”from June 2005 to March 2006 in the district.Our objective is to have all sex workers in all recreational places in the communities to use condoms whenever they have sex with their commercial clients . The project is organized by HIV/AIDS Preventive Project Office and supported by the Health Bureau of Dongcheng District. The public health administration is responsible for training recreational place owners on the “100% CUP” concept. In turn, the recreational place owners are required to inform sex workers in their places of the “100% CUP” project. The working staff for HIV/AIDS high-risk group intervention supervises, for twice, the effects of training at the recreation places and the implementation results. During the period, the working staff made two intensified intervention and questionnaires survey with the sex workers.
So far, the project progresses very well and has achieved satisfactory results, as shown in the following.
TARGETS AND METHODS
Targets
Managers, shift heads/managers/madams, formal and temporary sex workers in recreation places of the Dongcheng District.
Intervention Strategy
The 100% CUP strategy is separated into the five
activities including: advocacy for government commitment,coordination among various departments especially support of police,information, education and communication as well as behavioral change intervention, improving health services,monitoring and supervision. Focus on the measures of police participation, EE owners cooperation, behavior intervention and advocacy , along with condom social marketing in the society,realize the goal of reducing HIV infection by applying the principle of “ no condom, no sex” among target groups.
Advocacy and Training
On June 15~17, 2005, under the support of World Health Organization, Project Hope, and Clinton Foundation the Dongcheng District sponsored an “extended training course of medical staff for the control and prevention of HIV/AIDS”. It was attended by over 50 HIV/AIDS high-risk group intervention working team staff from disease prevention and control centers of the eight downtown districts in Beijing. Seven experts from Shanghai Family Planning Association, Chinese Center for Disease Control and Prevention, Guangxi Liuzhou Center for Disease Control and Prevention, Jiangsu Nanjing Center for Venereal Disease Control and Prevention and Project Hope served as instructors of the training course. The training course organized the students to visit gay bars and recreation places where the high-risk groups often meet, a means of field practice for the intervention of the high-risk groups. The training course was highly evaluated by the students as it effectively improved their operation skills and desensitization.
A professor from the WHO personally instructed the project of promoting 100% use of condoms in the recreation places in the Dongcheng District. He participated in discussions of the project team in the Dongcheng District, directed the district to establish an implementation plan for 100% use of condoms, and discussed with team members on the objectives, significance and operation methods of the project.
In the first half of last November, under the support of Wang Quan-yi, a research fellow from Beijing Center for Disease Control and Prevention, the project team established the implementation plan for December 2005. On November 18, the project team sponsored a coordination meeting attended by people from the family planning department, tourism bureau, public security bureau, health bureau and center for disease control and prevention in the district. The meeting solicited opinions from these functional organizations on how to carry out the project plan for December 2005. Dr. Zhao agreed in principle the implementation plan for the project.
On December 1, 2005, Dr. Zhao from WHO and professor Wang Quan-yi and professor Li Xiao-hong from Beijing Center for Disease Control and Prevention chaired a training course on extended HIV/AIDS prevention service for 50 community medical staff from 10 institutions in the Dongcheng District, including the health service center, health education institute, center for disease control and prevention, and venereal disease prevention institute. In this way, they prepared community-based human resources for the intervention of HIV/AIDS high-risk groups. They trained investigators and intervention working team members for the intervention among the high-risk groups.
On December 1,the Dongcheng District trained about 140 managers and owners from 71 recreation places in the district. The managers and business owners applauded to give their consent to Dr. Zhao from WHO, agreeing that the recreation place owners would do three things with the end of the training course. First, inform their staff of the use of condoms for HIV/AIDS prevention, require to adhere to the principle of “ no condom, no sex”. Second, train new workers thenceforward on the use of condoms for HIV/AIDS prevention. Third, after the training course, hang posters at the recreation places for HIV/AIDS prevention and extend propaganda materials on HIV/AIDS prevention. It was informed that staff of the district center for disease control and prevention would supervise the recreation places on the three promises in December 2005 and March 2006 respectively.
On December 8, Dr. Zhao personally trained 50 police from the Public Security Bureau of Dongcheng District regarding HIV/AIDS prevention policies and professional exposure and prevention of HIV/AIDS. Dr. Zhao reached consensus with the police on implementing the project of 100% CUP and on winning support of the public security bureau for the project.
On the basis of investigating condom demands, install condom-selling machines at free markets of agricultural products, guesthouses and hotels in the district.
Establish HIV/AIDS consulting hotlines and consulting sites at Beijing Center for Disease Control and Prevention, Dongcheng District Center for Disease Control and Prevention, and Beijing Ditan Hospital to offer free consultations for HIV infected people and patients. Extend 2 000 contact cards containing the telephone numbers of the three institutions to sex workers at the recreation places.
Calculate the number of people coming for advisory services on venereal diseases at the clinic of Ditan Hospital. Observe whether the number of people seeking advisory services has changed after the intervention project.
Organize 10 well-trained medical staff and health supervisors to 60 recreation places to evaluate the effects of the project and offer face-to-face consultations with 111 recreation place owners and 731 sex workers in these places on the topic of 100% use of condoms for HIV/AIDS prevention.
Evaluation Methods
The respondents are drawn out in the cluster random sampling method. The Dongcheng District project team establishes the supervision team, and the Beijing Center for Disease Control and Prevention composes the extended evaluation team. The project supervision team and the extended evaluation team surveyed the effects of 100% use of condoms at the recreation places on December 3~15, 2005 and March 14~21, 2006, respectively. In addition to the field surveys, they also investigated staff of the recreation places on their HIV/AIDS-related knowledge, attitudes, behaviors, and HIV/AIDS prevention know-how demands. They also surveyed the temporary sex workers on their use of condoms in the latest sex services and their demands for condoms. The extended evaluation team made field supervision in 15 recreation places in Dongcheng District regarding the quality of field surveys and questionnaire surveys by the AIDS project team and submitted a supervision report.
Qualitative surveyMake structural individual interviews with recreation place managers on such issues as the number of staff, whether their places are installed condom-selling machines, whether condoms are easily accessible, the time and contents of the training programs for the staff, and HIV/AIDS-related knowledge, attitudes and behaviors of the recreation place owners. The investigators also observe whether the places hang posters, ask the amounts of extended propaganda materials, and whether they sponsor other training courses.
Collect data reflecting the basic information of the clinic patients at the Venereal Disease and AIDS Control and Prevention Center of Ditan Hospital from December 2005 to March 2006, including their gender, age, profession, registered permanent residence and diagnosed diseases.
Collect policies on HIV/AIDS prevention that are promulgated by the Dongcheng District Government, Dongcheng District Center for Disease Control and Prevention, and member institutions for HIV/AIDS prevention during the intervention period, as well as information on their publicity activities.
Qualitative InterviewsRandomly pick out 5~10 temporary sex workers at each recreation place for questionnaire on HIV/AIDS prevention, HIV/AIDS infection and the use of condoms. Evaluate the effects of training for recreation place owners and their staff.
Selection of Questionnaires and InvestigatorsThe supervision team is consisted of well trained medical staff from health education institutes, hospitals, health supervision institutes, and venereal disease control and prevention institutes. The surveys are carried out with expert-designed questionnaires for sex workers anonymous and filled by the respondents and site structural questionnaires. The extended evaluation team comprises of personnel from Beijing Health Education Association and Beijing Center for Disease Control and Prevention.
Survey Quality ControlThe investigators do not explain the contents of the survey. The investigators may read the questionnaires to the respondents who could not read and write. However, the respondents choose the replies by themselves.
When the questionnaires are finished, the investigators need to check the questionnaires and ask the respondents to fill in or correct any omissions and logic errors in the very places.
In March 2006, Beijing Center for Disease Control and Prevention sent three specialists for double-blind extended evaluation of the quality of field surveys of sex workers at the 15 recreation places.
Data AnalysisUse Epidate 3.0 for database login and SPSS 11.0 for frequency distribution and mean proof-test.
RESULTS
Recreation Place Managers Perform Training Staff
In December 2005, 68 managers and on-duty shift heads of the recreation places were surveyed. In March 2006,7 recreation places were shut down, while two others opened business. In March 2006, 63 recreation places were surveyed. In December 2005, three managers replied they were never trained. In March 2006, 2 recreation places went into operation, whose owners were not trained. Subsequently, the investigators trained these recreation place owners.
In December 2005, the recreation places were trained for a total of 5 305 minutes. The shortest one lasted 20 minutes, and the longest, 180 minutes. A total of 2 822 workers were trained in the places, including 1 551 women and 1 261 men. The training program focused on venereal disease prevention, AIDS transmission channels, role of condoms in preventing HIV/AIDS and venereal diseases, and the idea of “no-condom,no-sex service”. On December 1,2005, 60% recreation place owners organized their staff for training. In March 2006, the 63 recreation places employed 1 984 formal workers, including 950 women and 1 034 men. They had a total of 1 414 rooms. On the day of survey, there were 1 379 temporary sex workers. Since the first intervention in December 2005, the recreation places held a total of 113 training courses on HIV/AIDS prevention, averaging 1.82 times in a place. In sum, 2 128 persons were trained. Some recreation places made a training each month.
The recreation places extended 1 947 copies of HIV/AIDS prevention-related propaganda materials. About 90% of the recreation places were hanged with propaganda pictures for HIV/AIDS prevention. A total of 388 persons watched videos on HIV/AIDS prevention, and 587 persons watched TV news on HIV/AIDS prevention. Besides, 105 persons from seven recreation places received blood tests for HIV/AIDS screening by the district center for disease control and prevention. And 48 persons called for consultations. In March 2006, we offered 690 condoms for free at 23 recreation places. Nine recreation places, totaling 14%, or the hotels they are based, have installed condom automatic selling machines.
And 54 recreation places, totaling 76%, replied condoms may be bought in nearby drugstores and supermarkets. Managers of 10 recreation places believed that drugstores and supermarkets have different working hours from recreation places, making it inconvenient to buy condoms. In December 2005, managers of three recreation places consulted on how to install automatic condom-selling machines. In March 2006, managers of 10 recreation places took the initiative to ask for help in installing automatic condom-selling machines.
Result of Questionnaire with Recreation Place Sex Workers
Survey Targets Our two surveys covered 731 sex workers, which were separated into 349 for 2005 and 382 for 2006. The sex workers had basically the same average ages, standing at 23.3 years old in 2005 and 23.1 years old in 2006. In the two surveys, the sex workers had essentially same education backgrounds, with 63.4% receiving senior high school education or above. In 2006, we also inquired the sex workers on their working hours in the recreation places. The result showed that 119 persons,totaling 31.2%,had worked in the places for one month, 108 persons totaling 28.3% had worked there for two to three months, and 155 persons totaling 40.6% had worked there for 4~6 months.
Respondents’ HIV/AIDS Related KnowledgeTo see Table 1.
Table 1 Respondents’ HIV/AIDS Knowledge(%)
Compared with the survey in December 2005, the respondents were apparently more aware of 4 of the 7 questions relating to HIV/AIDS and venereal diseases in 2006. Regarding the question on “HIV carriers showing no symptoms might infect others”, 72.5% sex workers said yes in December 2005 and 82.2% sex workers knew it in March 2006. As to the question that “One might not bear child when infected with venereal diseases”, the proportion of respondents knowing the result climbed from 75.6% in 2005 to 86.1% in 2006. The proportion of respondents acknowledging that “One might be infected with venereal diseases or HIV but unaware of it” rose from 81.9% in 2005 to 92.1% in 2006. Besides, 95% sex workers held that using condoms in a correct way might reduce the chances of HIV/AIDS infection.
Twice Intervention on Respondents and Their Latest Use of Condoms in Sexual ServiceThe sex workers had sex for the first time in their life when they reached 19 years old on average. The youngest was 14 years old, and the oldest was 29 years old. In the survey in 2005, 157 persons (45.6%) used condoms in their first sexual experience. In the survey in 2006, 150 persons (48.5%) used condoms in their first sexual life. In their latest sexual intercourses, 268 persons (77.9%) used condoms in the 2005 survey and 303 persons (81%) used condoms in the 2006 survey. The 2005 survey showed that the respondents spent 104 yuan on average for condoms in the past 12 months, and the figure stood at 132 yuan in the 2006 survey.To see Table 2.
Table 2 Sex Service of Sex Workers at Recreation Places in 2005 and 2006(%)
Acquaintance of Condom-Related Knowledge95% sex workers know that correct use of condoms might reduce the chances of HIV/AIDS infection. Regarding the question that “related organs need to offer condoms for free”, 147 persons (42.5%) agreed in 2005 and 200 persons (53.5%) agreed in 2006. In the 2006 survey, 305 sex workers (79.8%) replied that their recreation places made HIV/AIDS-related publicity works, and 329 persons (86%) knew the concept of “no condoms, no sex”.
Ditan Hospital Clinic Service for Venereal DiseasesCorrect medical treatment will be realized through intensifying correct healthcare education and advisory services, standardizing clinic services for venereal disease patients, and offering sound medical service environment and people-friendly services[1~4].
From December 2005 to February 2006, Ditan Hospital treated 8 126 persons for venereal diseases at the clinic. About 85% of the patients were local residents. Males accounted for 73.6% of the total. First comers amounted to 74.3%. Among them, 27% of the patients came to the clinic to have venereal diseases cured. On the whole, patients came to the clinic for physical examination and advisory service, totaling 15% and 45% respectively. The proportions were stabilized showing all kinds of patients going to the clinic for various purposes. It was not yet found more patients came for consultations.
DISCUSSION
The project is designed and implemented under the direct participation, guidance and demonstration of WHO experts[5~7].The double-blind extended evaluation method is applied to evaluate the quality of the survey data. The evaluation result showed that the project team was correct in choosing the appraisal method and the survey was reliable.
The Dongcheng District has basically built up a network for HIV/AIDS control and prevention that harmonizes efforts of various departments. The departments start to cooperate in HIV/AIDS prevention and intervention of recreation places, experiment methods for comprehensive behavior intervention among sex workers, and know the real situation and label the distribution of high-risk places in the communities.
Ditan Hospital has provided sound health services to venereal disease and HIV/AIDS patients and people coming for clinic and advisory services. Most of the people coming to the hospital were local residents. 60% of the clinic services provided physical examination and advisory services to patients. 74% patients were male, averaging 33 years old. Female venereal disease patients averaged 28 years old. No obvious changes were found regarding the proportions of patients coming to the hospital for medical treatment and advisory service from December 2005 to March 2006.
Since venereal disease patients register only in terms of whether they are local residents or from other places in the country, the effects of the intervention project of the Dongcheng District was hardly reflected in the change of patients coming for clinic service in Ditan Hospital.
Our survey showed that very few of the recreation places had installed condom-selling machines. Supermarkets and drugstores selling condoms are far away from the recreation places, and with different working hours. When asked if agree to have condom-selling machines installed near their places, most recreation place owners and managers nodded their heads.
With the implementation of the project, sex workers apparently had clearer idea on HIV/AIDS prevention. However, the rate of sex workers’ use of condoms in the latest sex service didn’t not improve much. Since sex workers are on frequent move in the recreation places, with about one third sex workers working for less than one month in the same recreation places, it is very hard to carry out the intervention program. As a result, the recreation place owners are required to fulfill three promises. However, in order to check up and evaluate how the recreation place owners carry out the three promises, related government organs need to establish standardized assessment mechanisms on HIV/AIDS prevention knowledge in the recreation places. They need to demand recreation place owners to record in written forms every time they train their staff workers, including signing in and the contents of training. They need to explore a set of sustaining strategies and methods for health promotion.
The survey showed that the managers were not so powerful in managing the sex workers, because they were simply short-term employers and employees. Many managers are even not so clear how many sex workers showed up in their places in a particular day. The managers said sex workers were highly independent to come to the places.
The survey result reminded us that only one or two training courses by recreation place owners would not be so effective to persuade or change the mindsets of sex workers to use condoms for a long period. Sex workers would move from one place to another. It demands the whole city or the whole district to make long-term education programs directing sex workers to use condoms in sex services. It is necessary to promote the concept of “no condoms, no sex service” so as to essentially persuade sex workers and brothel visitors to use condoms in the district[8].
In this way, it is a long-term mission to popularize HIV/AIDS prevention idea to recreation place workers. While recreation place owners must persevere in educating their staff, the health administration, health education department, health supervision department, and recreation place administration in the direct are also obliged to establish policies according to HIV/AIDS prevention provisions to supervise the judicial persons of the recreation places for organizing their staff to participate in training courses against HIV/AIDS. Related administrative organs must combine to periodically supervise the effects of the training courses. In particular, they need to intensify efforts promoting the knowledge on the use of condoms for HIV/AIDS prevention[9].
CONCLUSION
The project starts with training recreation place owners on the 100% use of condoms for HIV/AIDS prevention. In turn, the recreation place owners are required to educate sex workers in their places on the idea of 100% use of condoms for HIV/AIDS prevention. After two rounds of evaluation and supervision, 86% sex workers and all recreation place owners have accepted the idea of “no condoms, no sex service”. In their latest sex service, 80% sex workers used condoms. In order to achieve the scheduled objective of having all sex workers use condoms in sex service, the project team needs to make further intervention on the behavior of sex workers. It must intensify intervention with sex workers and brothel visitors and arrange sex educations for gays and lesbians. All related departments must positively support and devise all means to make it easier for recreation places to have condoms.
REFERENCES
1. Shen Jie, Cheng Feng,Yang Ping.Guide Manual of Comprehensive Intervention of Venereal Disease and HIV/AIDS. Second Military Medical University Publishing Company, 2002，9:108-110.
2. Chinese Center for Disease Control and Prevention.Working Directions for Intervention, Control and Prevention of Venereal Diseases and HIV/AIDS for Sex Workers at Recreation Places (Trial Version),2004.http://www.chinaids.org.cn/zhq/ShowContent.asp?lm=061&sn=2210 2.
3. Wang Ming, Deng Yanhong,Dong Haiying.Elements Influencing Gays in the Use of Condoms. China Health Education, 2005,21(7):527-528.
4. Fu Lijun, Shan Xingren,Zhang Yifeng.Survey of Recreation Place Sex Workers’ Knowledge of HIV/AIDS and Use of Condoms.China Health Education, 2005,21(12):916-917.
5. WHO. The Training Course of STI/HIV for the 100% Condom Use Programme. Geneva ,WHO， 2002,1-2.
6. WHO. The World Health Report 2004-Changing History.Geneva,WHO， 2004,9-27.
7. UN AIDS Evaluation of the 100% Condom Program in Thailand.Geneva ：UNAIDS , July，2000,1-2.
8. Zhang Liyan,Qiao Lei.Evaluation of Results of 100% condom Application Training Project.China Health Education, 2006,7(to be published).
9. Qiao Lei, Liu Yan,Zhou Shumin.Studies of Knowledge, Attitudes and Behaviors of Service Staff of Beijing Recreation Places on HIV/AIDS Control and Prevention.China Primary health care,2006,9(to be published).
1 WHO Collaborating Center for Urban Health Development , Beijing Dongcheng District,Beijing 100007,China
2 Beijing Center for Diseases Control and Prevetion, Beijing 100013,China
3 WHO Representative Office in China, Beijing 100060,China
4 Hepingli Hospital, Beijing 100013,China
5 Health Bureau of Dongcheng District , Beijing 100007,China
6 Health Inspection Institute of Dongcheng District , Beijing 100013,China
(Editor Jaque)(QIAO Lei1,WANG Quan-yi2,Z)
TEL:+86-10-64032562,E-mail:qiaolei@hotmail.com
[Abstract]ObjectiveTo implement the WHO recommended strategy 100% condom use programme(CUP) in entertainment establishments(EE) in the Dongcheng District,Beijing,China. MethodsAdopting WHO recommended 100% CUP strategy and start with training of EE owners and managers/madams on the concept of safer sex and the rule of “ no condom,no sex” during commercial sex business in order for reduction of HIV risk among sex workers and prevention of HIV spread from sex workers and their clients to general population. The EE owners were required to educate sex workers in their places whenever on arrival of new comers the notion of 100% use of condoms for HIV/AIDS prevention. Two assessment supervision and one extra evaluation were arranged in 3 months after launching. Results86% of the sex workers and 100% of the EE owners accepted the idea of “no condoms, no sex service”. 80% of the sex workers used condoms in the last commercial sex with male clients. Compared with 2005, 10% more sex workers became aware of HIV/ADIS-related knowledge. ConclusionsIn order to realize the set objectives of ensuring all sex workers of using condoms in sex services, the project team must go on regular supervision visit to the establishments, especially accompanying with police officer and promote social marketing strategy to ensure condom supply then make the 100% CUP a routine and sustainable practice in all EE in the Dongcheng District.
[Key words]HIV/AIDS prevention; 100% condom use programme; entertainment establishments;sex worker;condoms
INTRODUCTION
To promote intervention of HIV/AIDS among high-risk group and explore most effective manners and operation models in the Dongcheng District,Beijing,China, we start to implement the “100% condom use programme (100% CUP) ”from June 2005 to March 2006 in the district.Our objective is to have all sex workers in all recreational places in the communities to use condoms whenever they have sex with their commercial clients . The project is organized by HIV/AIDS Preventive Project Office and supported by the Health Bureau of Dongcheng District. The public health administration is responsible for training recreational place owners on the “100% CUP” concept. In turn, the recreational place owners are required to inform sex workers in their places of the “100% CUP” project. The working staff for HIV/AIDS high-risk group intervention supervises, for twice, the effects of training at the recreation places and the implementation results. During the period, the working staff made two intensified intervention and questionnaires survey with the sex workers.
So far, the project progresses very well and has achieved satisfactory results, as shown in the following.
TARGETS AND METHODS
Targets
Managers, shift heads/managers/madams, formal and temporary sex workers in recreation places of the Dongcheng District.
Intervention Strategy
The 100% CUP strategy is separated into the five
activities including: advocacy for government commitment,coordination among various departments especially support of police,information, education and communication as well as behavioral change intervention, improving health services,monitoring and supervision. Focus on the measures of police participation, EE owners cooperation, behavior intervention and advocacy , along with condom social marketing in the society,realize the goal of reducing HIV infection by applying the principle of “ no condom, no sex” among target groups.
Advocacy and Training
On June 15~17, 2005, under the support of World Health Organization, Project Hope, and Clinton Foundation the Dongcheng District sponsored an “extended training course of medical staff for the control and prevention of HIV/AIDS”. It was attended by over 50 HIV/AIDS high-risk group intervention working team staff from disease prevention and control centers of the eight downtown districts in Beijing. Seven experts from Shanghai Family Planning Association, Chinese Center for Disease Control and Prevention, Guangxi Liuzhou Center for Disease Control and Prevention, Jiangsu Nanjing Center for Venereal Disease Control and Prevention and Project Hope served as instructors of the training course. The training course organized the students to visit gay bars and recreation places where the high-risk groups often meet, a means of field practice for the intervention of the high-risk groups. The training course was highly evaluated by the students as it effectively improved their operation skills and desensitization.
A professor from the WHO personally instructed the project of promoting 100% use of condoms in the recreation places in the Dongcheng District. He participated in discussions of the project team in the Dongcheng District, directed the district to establish an implementation plan for 100% use of condoms, and discussed with team members on the objectives, significance and operation methods of the project.
In the first half of last November, under the support of Wang Quan-yi, a research fellow from Beijing Center for Disease Control and Prevention, the project team established the implementation plan for December 2005. On November 18, the project team sponsored a coordination meeting attended by people from the family planning department, tourism bureau, public security bureau, health bureau and center for disease control and prevention in the district. The meeting solicited opinions from these functional organizations on how to carry out the project plan for December 2005. Dr. Zhao agreed in principle the implementation plan for the project.
On December 1, 2005, Dr. Zhao from WHO and professor Wang Quan-yi and professor Li Xiao-hong from Beijing Center for Disease Control and Prevention chaired a training course on extended HIV/AIDS prevention service for 50 community medical staff from 10 institutions in the Dongcheng District, including the health service center, health education institute, center for disease control and prevention, and venereal disease prevention institute. In this way, they prepared community-based human resources for the intervention of HIV/AIDS high-risk groups. They trained investigators and intervention working team members for the intervention among the high-risk groups.
On December 1,the Dongcheng District trained about 140 managers and owners from 71 recreation places in the district. The managers and business owners applauded to give their consent to Dr. Zhao from WHO, agreeing that the recreation place owners would do three things with the end of the training course. First, inform their staff of the use of condoms for HIV/AIDS prevention, require to adhere to the principle of “ no condom, no sex”. Second, train new workers thenceforward on the use of condoms for HIV/AIDS prevention. Third, after the training course, hang posters at the recreation places for HIV/AIDS prevention and extend propaganda materials on HIV/AIDS prevention. It was informed that staff of the district center for disease control and prevention would supervise the recreation places on the three promises in December 2005 and March 2006 respectively.
On December 8, Dr. Zhao personally trained 50 police from the Public Security Bureau of Dongcheng District regarding HIV/AIDS prevention policies and professional exposure and prevention of HIV/AIDS. Dr. Zhao reached consensus with the police on implementing the project of 100% CUP and on winning support of the public security bureau for the project.
On the basis of investigating condom demands, install condom-selling machines at free markets of agricultural products, guesthouses and hotels in the district.
Establish HIV/AIDS consulting hotlines and consulting sites at Beijing Center for Disease Control and Prevention, Dongcheng District Center for Disease Control and Prevention, and Beijing Ditan Hospital to offer free consultations for HIV infected people and patients. Extend 2 000 contact cards containing the telephone numbers of the three institutions to sex workers at the recreation places.
Calculate the number of people coming for advisory services on venereal diseases at the clinic of Ditan Hospital. Observe whether the number of people seeking advisory services has changed after the intervention project.
Organize 10 well-trained medical staff and health supervisors to 60 recreation places to evaluate the effects of the project and offer face-to-face consultations with 111 recreation place owners and 731 sex workers in these places on the topic of 100% use of condoms for HIV/AIDS prevention.
Evaluation Methods
The respondents are drawn out in the cluster random sampling method. The Dongcheng District project team establishes the supervision team, and the Beijing Center for Disease Control and Prevention composes the extended evaluation team. The project supervision team and the extended evaluation team surveyed the effects of 100% use of condoms at the recreation places on December 3~15, 2005 and March 14~21, 2006, respectively. In addition to the field surveys, they also investigated staff of the recreation places on their HIV/AIDS-related knowledge, attitudes, behaviors, and HIV/AIDS prevention know-how demands. They also surveyed the temporary sex workers on their use of condoms in the latest sex services and their demands for condoms. The extended evaluation team made field supervision in 15 recreation places in Dongcheng District regarding the quality of field surveys and questionnaire surveys by the AIDS project team and submitted a supervision report.
Qualitative surveyMake structural individual interviews with recreation place managers on such issues as the number of staff, whether their places are installed condom-selling machines, whether condoms are easily accessible, the time and contents of the training programs for the staff, and HIV/AIDS-related knowledge, attitudes and behaviors of the recreation place owners. The investigators also observe whether the places hang posters, ask the amounts of extended propaganda materials, and whether they sponsor other training courses.
Collect data reflecting the basic information of the clinic patients at the Venereal Disease and AIDS Control and Prevention Center of Ditan Hospital from December 2005 to March 2006, including their gender, age, profession, registered permanent residence and diagnosed diseases.
Collect policies on HIV/AIDS prevention that are promulgated by the Dongcheng District Government, Dongcheng District Center for Disease Control and Prevention, and member institutions for HIV/AIDS prevention during the intervention period, as well as information on their publicity activities.
Qualitative InterviewsRandomly pick out 5~10 temporary sex workers at each recreation place for questionnaire on HIV/AIDS prevention, HIV/AIDS infection and the use of condoms. Evaluate the effects of training for recreation place owners and their staff.
Selection of Questionnaires and InvestigatorsThe supervision team is consisted of well trained medical staff from health education institutes, hospitals, health supervision institutes, and venereal disease control and prevention institutes. The surveys are carried out with expert-designed questionnaires for sex workers anonymous and filled by the respondents and site structural questionnaires. The extended evaluation team comprises of personnel from Beijing Health Education Association and Beijing Center for Disease Control and Prevention.
Survey Quality ControlThe investigators do not explain the contents of the survey. The investigators may read the questionnaires to the respondents who could not read and write. However, the respondents choose the replies by themselves.
When the questionnaires are finished, the investigators need to check the questionnaires and ask the respondents to fill in or correct any omissions and logic errors in the very places.
In March 2006, Beijing Center for Disease Control and Prevention sent three specialists for double-blind extended evaluation of the quality of field surveys of sex workers at the 15 recreation places.
Data AnalysisUse Epidate 3.0 for database login and SPSS 11.0 for frequency distribution and mean proof-test.
RESULTS
Recreation Place Managers Perform Training Staff
In December 2005, 68 managers and on-duty shift heads of the recreation places were surveyed. In March 2006,7 recreation places were shut down, while two others opened business. In March 2006, 63 recreation places were surveyed. In December 2005, three managers replied they were never trained. In March 2006, 2 recreation places went into operation, whose owners were not trained. Subsequently, the investigators trained these recreation place owners.
In December 2005, the recreation places were trained for a total of 5 305 minutes. The shortest one lasted 20 minutes, and the longest, 180 minutes. A total of 2 822 workers were trained in the places, including 1 551 women and 1 261 men. The training program focused on venereal disease prevention, AIDS transmission channels, role of condoms in preventing HIV/AIDS and venereal diseases, and the idea of “no-condom,no-sex service”. On December 1,2005, 60% recreation place owners organized their staff for training. In March 2006, the 63 recreation places employed 1 984 formal workers, including 950 women and 1 034 men. They had a total of 1 414 rooms. On the day of survey, there were 1 379 temporary sex workers. Since the first intervention in December 2005, the recreation places held a total of 113 training courses on HIV/AIDS prevention, averaging 1.82 times in a place. In sum, 2 128 persons were trained. Some recreation places made a training each month.
The recreation places extended 1 947 copies of HIV/AIDS prevention-related propaganda materials. About 90% of the recreation places were hanged with propaganda pictures for HIV/AIDS prevention. A total of 388 persons watched videos on HIV/AIDS prevention, and 587 persons watched TV news on HIV/AIDS prevention. Besides, 105 persons from seven recreation places received blood tests for HIV/AIDS screening by the district center for disease control and prevention. And 48 persons called for consultations. In March 2006, we offered 690 condoms for free at 23 recreation places. Nine recreation places, totaling 14%, or the hotels they are based, have installed condom automatic selling machines.
And 54 recreation places, totaling 76%, replied condoms may be bought in nearby drugstores and supermarkets. Managers of 10 recreation places believed that drugstores and supermarkets have different working hours from recreation places, making it inconvenient to buy condoms. In December 2005, managers of three recreation places consulted on how to install automatic condom-selling machines. In March 2006, managers of 10 recreation places took the initiative to ask for help in installing automatic condom-selling machines.
Result of Questionnaire with Recreation Place Sex Workers
Survey Targets Our two surveys covered 731 sex workers, which were separated into 349 for 2005 and 382 for 2006. The sex workers had basically the same average ages, standing at 23.3 years old in 2005 and 23.1 years old in 2006. In the two surveys, the sex workers had essentially same education backgrounds, with 63.4% receiving senior high school education or above. In 2006, we also inquired the sex workers on their working hours in the recreation places. The result showed that 119 persons,totaling 31.2%,had worked in the places for one month, 108 persons totaling 28.3% had worked there for two to three months, and 155 persons totaling 40.6% had worked there for 4~6 months.
Respondents’ HIV/AIDS Related KnowledgeTo see Table 1.
Table 1 Respondents’ HIV/AIDS Knowledge(%)
Compared with the survey in December 2005, the respondents were apparently more aware of 4 of the 7 questions relating to HIV/AIDS and venereal diseases in 2006. Regarding the question on “HIV carriers showing no symptoms might infect others”, 72.5% sex workers said yes in December 2005 and 82.2% sex workers knew it in March 2006. As to the question that “One might not bear child when infected with venereal diseases”, the proportion of respondents knowing the result climbed from 75.6% in 2005 to 86.1% in 2006. The proportion of respondents acknowledging that “One might be infected with venereal diseases or HIV but unaware of it” rose from 81.9% in 2005 to 92.1% in 2006. Besides, 95% sex workers held that using condoms in a correct way might reduce the chances of HIV/AIDS infection.
Twice Intervention on Respondents and Their Latest Use of Condoms in Sexual ServiceThe sex workers had sex for the first time in their life when they reached 19 years old on average. The youngest was 14 years old, and the oldest was 29 years old. In the survey in 2005, 157 persons (45.6%) used condoms in their first sexual experience. In the survey in 2006, 150 persons (48.5%) used condoms in their first sexual life. In their latest sexual intercourses, 268 persons (77.9%) used condoms in the 2005 survey and 303 persons (81%) used condoms in the 2006 survey. The 2005 survey showed that the respondents spent 104 yuan on average for condoms in the past 12 months, and the figure stood at 132 yuan in the 2006 survey.To see Table 2.
Table 2 Sex Service of Sex Workers at Recreation Places in 2005 and 2006(%)
Acquaintance of Condom-Related Knowledge95% sex workers know that correct use of condoms might reduce the chances of HIV/AIDS infection. Regarding the question that “related organs need to offer condoms for free”, 147 persons (42.5%) agreed in 2005 and 200 persons (53.5%) agreed in 2006. In the 2006 survey, 305 sex workers (79.8%) replied that their recreation places made HIV/AIDS-related publicity works, and 329 persons (86%) knew the concept of “no condoms, no sex”.
Ditan Hospital Clinic Service for Venereal DiseasesCorrect medical treatment will be realized through intensifying correct healthcare education and advisory services, standardizing clinic services for venereal disease patients, and offering sound medical service environment and people-friendly services[1~4].
From December 2005 to February 2006, Ditan Hospital treated 8 126 persons for venereal diseases at the clinic. About 85% of the patients were local residents. Males accounted for 73.6% of the total. First comers amounted to 74.3%. Among them, 27% of the patients came to the clinic to have venereal diseases cured. On the whole, patients came to the clinic for physical examination and advisory service, totaling 15% and 45% respectively. The proportions were stabilized showing all kinds of patients going to the clinic for various purposes. It was not yet found more patients came for consultations.
DISCUSSION
The project is designed and implemented under the direct participation, guidance and demonstration of WHO experts[5~7].The double-blind extended evaluation method is applied to evaluate the quality of the survey data. The evaluation result showed that the project team was correct in choosing the appraisal method and the survey was reliable.
The Dongcheng District has basically built up a network for HIV/AIDS control and prevention that harmonizes efforts of various departments. The departments start to cooperate in HIV/AIDS prevention and intervention of recreation places, experiment methods for comprehensive behavior intervention among sex workers, and know the real situation and label the distribution of high-risk places in the communities.
Ditan Hospital has provided sound health services to venereal disease and HIV/AIDS patients and people coming for clinic and advisory services. Most of the people coming to the hospital were local residents. 60% of the clinic services provided physical examination and advisory services to patients. 74% patients were male, averaging 33 years old. Female venereal disease patients averaged 28 years old. No obvious changes were found regarding the proportions of patients coming to the hospital for medical treatment and advisory service from December 2005 to March 2006.
Since venereal disease patients register only in terms of whether they are local residents or from other places in the country, the effects of the intervention project of the Dongcheng District was hardly reflected in the change of patients coming for clinic service in Ditan Hospital.
Our survey showed that very few of the recreation places had installed condom-selling machines. Supermarkets and drugstores selling condoms are far away from the recreation places, and with different working hours. When asked if agree to have condom-selling machines installed near their places, most recreation place owners and managers nodded their heads.
With the implementation of the project, sex workers apparently had clearer idea on HIV/AIDS prevention. However, the rate of sex workers’ use of condoms in the latest sex service didn’t not improve much. Since sex workers are on frequent move in the recreation places, with about one third sex workers working for less than one month in the same recreation places, it is very hard to carry out the intervention program. As a result, the recreation place owners are required to fulfill three promises. However, in order to check up and evaluate how the recreation place owners carry out the three promises, related government organs need to establish standardized assessment mechanisms on HIV/AIDS prevention knowledge in the recreation places. They need to demand recreation place owners to record in written forms every time they train their staff workers, including signing in and the contents of training. They need to explore a set of sustaining strategies and methods for health promotion.
The survey showed that the managers were not so powerful in managing the sex workers, because they were simply short-term employers and employees. Many managers are even not so clear how many sex workers showed up in their places in a particular day. The managers said sex workers were highly independent to come to the places.
The survey result reminded us that only one or two training courses by recreation place owners would not be so effective to persuade or change the mindsets of sex workers to use condoms for a long period. Sex workers would move from one place to another. It demands the whole city or the whole district to make long-term education programs directing sex workers to use condoms in sex services. It is necessary to promote the concept of “no condoms, no sex service” so as to essentially persuade sex workers and brothel visitors to use condoms in the district[8].
In this way, it is a long-term mission to popularize HIV/AIDS prevention idea to recreation place workers. While recreation place owners must persevere in educating their staff, the health administration, health education department, health supervision department, and recreation place administration in the direct are also obliged to establish policies according to HIV/AIDS prevention provisions to supervise the judicial persons of the recreation places for organizing their staff to participate in training courses against HIV/AIDS. Related administrative organs must combine to periodically supervise the effects of the training courses. In particular, they need to intensify efforts promoting the knowledge on the use of condoms for HIV/AIDS prevention[9].
CONCLUSION
The project starts with training recreation place owners on the 100% use of condoms for HIV/AIDS prevention. In turn, the recreation place owners are required to educate sex workers in their places on the idea of 100% use of condoms for HIV/AIDS prevention. After two rounds of evaluation and supervision, 86% sex workers and all recreation place owners have accepted the idea of “no condoms, no sex service”. In their latest sex service, 80% sex workers used condoms. In order to achieve the scheduled objective of having all sex workers use condoms in sex service, the project team needs to make further intervention on the behavior of sex workers. It must intensify intervention with sex workers and brothel visitors and arrange sex educations for gays and lesbians. All related departments must positively support and devise all means to make it easier for recreation places to have condoms.
REFERENCES
1. Shen Jie, Cheng Feng,Yang Ping.Guide Manual of Comprehensive Intervention of Venereal Disease and HIV/AIDS. Second Military Medical University Publishing Company, 2002，9:108-110.
2. Chinese Center for Disease Control and Prevention.Working Directions for Intervention, Control and Prevention of Venereal Diseases and HIV/AIDS for Sex Workers at Recreation Places (Trial Version),2004.http://www.chinaids.org.cn/zhq/ShowContent.asp?lm=061&sn=2210 2.
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5. WHO. The Training Course of STI/HIV for the 100% Condom Use Programme. Geneva ,WHO， 2002,1-2.
6. WHO. The World Health Report 2004-Changing History.Geneva,WHO， 2004,9-27.
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8. Zhang Liyan,Qiao Lei.Evaluation of Results of 100% condom Application Training Project.China Health Education, 2006,7(to be published).
9. Qiao Lei, Liu Yan,Zhou Shumin.Studies of Knowledge, Attitudes and Behaviors of Service Staff of Beijing Recreation Places on HIV/AIDS Control and Prevention.China Primary health care,2006,9(to be published).
1 WHO Collaborating Center for Urban Health Development , Beijing Dongcheng District,Beijing 100007,China
2 Beijing Center for Diseases Control and Prevetion, Beijing 100013,China
3 WHO Representative Office in China, Beijing 100060,China
4 Hepingli Hospital, Beijing 100013,China
5 Health Bureau of Dongcheng District , Beijing 100007,China
6 Health Inspection Institute of Dongcheng District , Beijing 100013,China
(Editor Jaque)(QIAO Lei1,WANG Quan-yi2,Z)