January 2001

Promoting 100 Percent Condom Use in
Dominican Sex Establishments

Thailand’s 100 Percent Condom Program has been credited with significant increases in consistent condom use and declining incidence of sexually transmitted infections (STIs) among female sex workers and their clients. Its success has prompted many to ask if similar programs could be adapted for other settings. In the Dominican Republic two local NGOs—Centro de Orientación e Investigación Integral (COIN) and Centro de Promoción de Solidaridad Humana (CEPROSH)—are working in coordination with the National Program for the Control of Sexually Transmitted Diseases and AIDS (DIGECITSS) to test two models of an adapted version of the Thai program:

• A solidarity-based approach to 100 percent condom use in selected sex establishments in Santo Domingo that encourages voluntary compliance through mobilization and education.
   
• A solidarity approach combined with government regulation and enforcement in Puerto Plata.

Intervention Components

The two models were developed after extensive formative research and in consultation with sex worker peer leaders (mensajeras líderes) and the sex worker union MODEMU. The models also build on HIV/AIDS peer education efforts that have been ongoing in the Dominican Republic for more than a decade.

Both models include participatory workshops and educational materials that emphasize a collective commitment (compromiso colectivo) to 100 percent condom use by female sex workers, sex establishment owners/managers, and other establishment employees. The participatory workshops also focus on how trust and intimacy inhibit condom use between sex workers and their regular paying and non-paying partners. In addition, both models use such environmental cues as visible supplies of condoms and 100 percent condom use posters in the sex establishments. Government health inspectors accompanied by NGO staff visit all establishments each month to encourage sex workers to be screened monthly for STIs and check that STI cards validating attendance at the STI clinics are updated. In Puerto Plata, sex establishment owners are informed of the regional government policy mandating condom use between sex workers and clients and of the penalties for non-compliance.

In both Puerto Plata and Santo Domingo, sex establishment owners are notified of their compliance or non-compliance with key intervention elements (e.g., presence of condoms and 100 percent condom posters in the establishment, attendance of sex workers at monthly STI checks, and lack of a positive STI diagnosis among the sex workers) at the end of each month. Those owners who are not in compliance in Santo Domingo receive additional educational efforts to build compliance. Those who do not comply in Puerto Plata are subject to a graduated sanction system, including potential fines and closings. If a sex worker is diagnosed with an STI, a sex worker peer educator informs her confidentially. Establishment owners are informed whether any STIs have been detected at the sex establishment each month, but to protect confidentiality, are not told which sex workers are infected.

Study Methods

The intervention study is being conducted in 68 sex establishments, 34 in each city. The research uses a multi-site pre/post test design with historic controls measuring STI prevalence over a six-month period prior to the commencement of the intervention. The impact of the intervention is assessed with a composite measure of compliance that includes STI prevalence and self-reported data on consistent condom use.

Research teams conducted surveys of sexual risk behavior and biomedical testing for STIs with 418 female sex workers prior to the intervention in Puerto Plata and in parts of Santo Domingo. Sex workers from the 68 sex establishments in both cities were randomly selected at public and semi-public STI clinics to participate in the survey. All sex workers who expressed interest in participating received detailed information, and informed consent was obtained from each participant. LCR tests for gonorrhea and chlamydia were conducted on urine samples, VDRL and FTA-ABS tests for syphilis were conducted on blood samples, and the KOH test to detect candidiasis, gardnerella, and trichomoniasis was conducted with cervical samples collected from each participant. All women testing positive for STIs were treated.

Key Baseline Findings

Barely half of sex workers reported using condoms consistently. Table 1 demonstrates the variation in consistent condom use across partner types. When sex workers were asked about condom use in the last month, 50.3 percent (80/159) from Santo Domingo and 42.2 percent (81/192) from Puerto Plata reported that they used condoms consistently with all of their partners (regardless of type of partner). When asked if they use condoms consistently with their new clients, 75.3 percent (70/93) of sex workers from Santo Domingo and 96.5 percent (111/115) from Puerto Plata stated that they always use condoms with their new clients.

Yet a much lower percent—14.6 percent (21/144) in Santo Domingo and 13.0 percent (17/131) in Puerto Plata—stated that they always use condoms with regular partners or partners of trust. According to reports from sex workers in Puerto Plata, approximately 25 percent of these regular partners either pay the sex establishment quota to have sex with the woman or pay the woman directly for sex. Thus many of these regular partners cannot be considered purely "private" or "noncommercial" relationships and therefore may be influenced by the sex establishment environment and policies.

Nearly a third of sex workers had at least one STI. Thirty-two percent of 418 sex workers from the participating sex establishments in Santo Domingo and Puerto Plata tested positive for either gonorrhea, syphilis, trichomoniasis, or chlamydia. Table 2 shows the baseline prevalence of these STIs among the study sample. Less than 10 percent of women from each of the two cities tested positive for gonorrhea, syphilis, or trichomoniasis, respectively. However, rates of chlamydia were surprisingly high: 16.4 percent in Santo Domingo and 14.6 percent in Puerto Plata. The prevalence of chlamydia in one clinic in Santo Domingo was 27.4 percent. Government STI clinics in the Dominican Republic generally use syndromic management combined with STI screening tools with relatively low sensitivity, such as gram stain for gonorrhea and VDRL for syphilis. No testing is done on a regular basis for chlamydial infections, which may explain the high rates of existing cases.

Conclusions

In countries such as the Dominican Republic that have well-established HIV epidemics and ongoing educational programs targeting sex workers, relational and environmental-structural barriers to HIV/STI prevention must be addressed in order to achieve significant changes in current condom use and STI transmission rates.

Baseline data indicate that condom promotion activities must emphasize the risk of HIV/STI infection that exists for sex workers with both their regular paying and non-paying partners. A combination of consciousness/solidarity-building and policy/regulatory activities are currently being implemented to address this issue.

The study is being implemented by Centro de Orientación e Investigación Integral (COIN), Centro de Promoción y Solidaridad Humana (CEPROSH), Johns Hopkins School of Public Health, and the Horizons Project.

For more information, please contact Deanna Kerrigan  (dkerrigan@popcouncil.org) or Luis Moreno (coin@codetel.net.do) or Ellen Weiss (eweiss@popcouncil.org).

About Horizons

Horizons conducts global operations research to improve prevention, care, and support program. Horizons is implemented by the Population Council under a cooperative agreement with the U.S. Agency for International Development. Horizons is implemented by the Population Council in partnership with the International Center for Research on Women (ICRW), the Program for Appropriate Technology in Health (PATH), the International HIV/AIDS Alliance, Tulane University, and the University of Alabama at Birmingham.

Copyright © 2001 The Population Council

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19 Nov 2007