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Consistent Condom Use and Risky Drug Injecting Behavior among
Sex Workers in Vietnam: Implications for Programming
:: BACKGROUND
PSI/Vietnam is implementing a PEPFAR-funded outreach intervention that works to decrease HIV infection among female sex workers who are also injecting drug users (SW-IDUs) in four provinces: Hai Phong, Quang Ninh, Ho Chi Minh
City (HCMC) and Nghe An. In addition, PSI is reaching non-IDU SWs with indirect HIV prevention interventions in seven PEPFAR priority provinces (Hanoi, Hai Phong, Quang Ninh, Nghe An, HCMC, Can Tho and An Giang provinces).
SW-IDUs face a dual risk of HIV infection due to high-risk sex and unsafe injecting behavior. The project’s goal is to
reduce this risk by promoting safer sexual and injecting behaviors and by discouraging initiation into injecting drug use
among sex workers who are currently inhaling or are exposed to drug use. The program’s objectives include increased
consistent condom use (male and female), increased utilization of HIV voluntary counseling and testing (VCT) services, and reduced initiation of injecting drug use among non-IDU SWs.
:: SUMMARY OF RESEARCH
In 2008, PSI conducted a behavioral study among 765 SWs and 233 SW-IDUs aged 18-35. SWs were drawn from
six project provinces and SW-IDUs from two. The study employed respondent-driven sampling to recruit study participants. SW-IDU recruitment was conducted independently of SW recruitment.
Results from the study provided descriptive data on population characteristics, sexual behaviors, consistent condom
use in high risk relationships, uptake of VCT services and three IDU behaviors linked to the initiation of injecting drug
use by existing SW-IDU:
:: Helping someone to inject for the first time.
:: Injecting in the presence of a non-IDU.
:: Talking about the benefits of injecting drug use in front of a non-IDU.
::
Summary of Study Findings
:: There is potential to improve consistent condom use with clients. Key behavioral determinants affecting
condom use are low levels of belief that condoms should be used regardless of physical appearance of
male clients and low levels of self-efficacy for negotiating condom use with clients.
:: SW-IDUs had more clients on average than other SWs and were less able to negotiate condom use
due to ‘drug hunger’ and economic factors.
:: Overall, uptake of VCT services was low and needs to be significantly improved. Awareness of VCT site
locations was a strong determinant of this behavior.
:: SWs initiated other SWs into injecting drug use – not male partners or clients as commonly believed.
:: STUDY FINDINGS AND PROGRAMMATIC IMPLICATIONS
POPULATION CHARACTERISTICS
Most SWs attended at least secondary schooling and the majority are not married or living with a sexual partner. SWs
most frequently accessed clients in the street, in parks and in cafes, with SW-IDUs more likely to be street-based. SWs
tend to work independently and not under the management of an entertainment establishment owner.
PSI, in partnership with the provincial government agencies (Provincial Health Department and Provincial
AIDS Centers), has recruited peer outreach teams to reach SWs in the settings where they access clients.
Peer outreach teams are trained quarterly and work closely with sex workers to promote key health messages, utilizing evidence-based interpersonal communication (IPC) tools and social marketing approaches.
CONDOM USAGE
Consistent condom use in high-risk relationships among SWs is low and needs to be improved. On average, 66 percent
reported consistent condom use with male clients during vaginal sex. Of the 56 percent of SWs who reported sex with a
non-commercial partner, only 25 percent reported consistent condom use.
SWs agreed that condoms were available, affordable and efficacious at reducing the risk of HIV transmission. The biggest factors that reduce consistent condom use among SWs are: belief that the SWs can tell which clients are safe based
on their appearance, belief that clients have the right to decide whether or not to use condoms and the belief that they
cannot afford to lose business for the fear that a client would leave if asked to use a condom.
PSI is working to shift beliefs associated with low rates of consistent condom use. Outreach workers, using
IPC tools and information, education and communication materials, help SWs to build their skills to effectively
negotiate condom use, while simultaneously countering the belief that one can assess risk based on appearance. In addition to delivering these messages, PSI also promotes Number One male condoms, Care female
condoms and Number One Plus water-based lubricants (for combined use with condoms).
HIV TESTING
50
42
% of sex workers surveyed
40
HIV Testing & SWs
30
20
10
0
Ever tested for HIV
16
Ever received VCT
Less than half (42 percent) of SWs had ever been tested for HIV and even fewer (16 percent) had ever received VCT
services. Most HIV testing occurred at public health facilities, including PEPFAR-funded Chan Troi Moi (CTM) VCT sites.
46 percent of SWs learned about the PEPFAR-funded VCT sites through PSI’s Chan Troi Moi (New Horizons) campaign
in mass media channels. Those exposed to the campaign are more likely to access VCT services.
Although a high percentage of respondents were aware of VCT, only 11 percent of SWs knew the location of a CTM
Center. The main reasons cited for not getting an HIV test included a belief that they were not infected, fear of a positive
result and no knowledge of where to access counseling and testing services.
PSI’s activities concentrate on improving awareness of VCT site locations through outreach and mass media
channels. Outreach teams promote the importance of knowing one’s HIV status, offer referrals to VCT and
provide escorts to services when individuals indicate a need for support.
INITIATION INTO INJECTING DRUG USE
Behaviors that encourage the initiation of injecting among non-injectors were common in the SW-IDU population. SWIDUs were most commonly initiated into injecting by other SWs (59 percent). Although only 11 percent of SW-IDUs
reported assisting non-injectors to inject for the first time, those who did assist reported assisting nearly six people in
the previous six months. More than one third of SW-IDUs injected in front of non-injectors and spoke of the benefits of
injecting to them.
40
37
% of SW-IDUs surveyed
SW-IDUs
Helped someone inject
for the first time
30
20
36
17
10
Injected in front of a noninjector
Talked about the benefits
of injecting in front of a
non-injector
0
Drug demand reduction interventions use evidence-based and interactive communication tools to encourage
behavior change among SW-IDUs. By changing SW-IDUs behavior in front of non-injectors, PSI seeks to
reduce the number of SWs shifting from inhalation of opiates to injecting.
:: TRACKING PROGRESS WITH EFFECTIVE MONITORING
This study indentified a number of key messages that needed to reach unique subgroups within the sex worker population. For example, drug demand reduction messages need to target not sex workers who are injecting drug users, but
specifically sex workers inhaling opiates or exposed to drug use. This need for a high degree of tailoring presented a
significant monitoring challenge.
In response, PSI/Vietnam employed a unique identifier code (UIC) system with its outreach workers. In this system, each
SW is assigned a unique number. This number is recorded every time an individual is reached with products, services or
behavior changes messages.
Tracking data linked to the UIC, PSI can ensure that each sex worker is receiving the proper targeted messages and that
messages are delivered at a frequency to effect behavior change. Utilizing the UIC, PSI can also monitor product distribution and tailor distribution plans to reach the populations most in need of the product.
Finally, the UIC system allows tracking of individual sex workers (not just repeat contacts). This helps estimate the target
population size in a geographic area, monitor frequency of messaging and track messages by sub-target group. This
evidence-based monitoring approach has allowed PSI to track contact with 5,000 unique sex workers in two provinces –
one of the largest outreach interventions in Vietnam.