Are Preventive HIV Interventions at Airports Effective?
Thomas 111.Gehring,]eannette Widmer, Dieter Kleiber, and Robert Stefen
Background: Few empirical data exist on the impact of preventive human immunodeficiency virus (HIV) interventions on
intended and actual sexual behavior of international tourists.The present cross-sectional study is based on a 2 X 2 design.
Methods: The sample consisted of departing and arriving passengers (n = 3100) at Zurich Airport with destinations i n
countries where heterosexual HIV transmission is dominant. While 41% of the tourists obtained information about safer
sex, the remaining 59% without such intervention served as control group. Departing passengers completed a short questionnaire focusing on their planned sexual behavior. Arriving passengers were asked about their actual behavior during
the journey. Subjects of the intervention group also evaluated the impact of the consultation.
Results: Most travelers appreciated the intervention and reported that they received important information. Members of
the intervention group were better informed than those of the control group about the risk of heterosexually transmitted
HIV infection (p c .Ol).They also indicated more often that they could imagine having casual sex abroad (23% vs 16%. p <
.01). However, the t w o groups did not differ with regard to planned condom use or actual sexual behavior. Whereas most
of departing passengers indicated that they would use condoms consistently, only half of the passengers who reported
casual sex actually did so. Subjects who refused to participate in the intervention tended to consider it as irrelevant and
reported less consistent condom use.
Conclusions: Although travel health interventions focusing on casual sex are appreciated and increase the knowledge,
they failed t o result i n significant behavior modification. Future projects should attempt to approach possible risk groups
more specifically and t o have more impact.
limited economical resources which are popular tourism
and business destinations (e.g., Southeast Asia, Caribbean
and South America) are characterized by a high increase
of HIV infections.' For example, HIV prevalence among
organized prostitutes in Thailand increased from 3.5% to
33% between 1989 and 1994, and that among prostitutes
in Bombay from 1% to 51% between 1987 and 1993.3
In Europe, international tourism and migration are
associated with up to one third of new HIV infections
among heterosexual adult^.^,^,' For the Swiss population
there are no statistics about the number of people who
were infected abroad. However, according to the Swiss
Federal Office of Public Health the proportion of new
infections among the heterosexual population increased
sharply from 6.1% to 42.6% between 1985 and 1995.'
Presumably, the virus was transmitted by HIV-positive
sex partners who had injected drugs or lived in developing countries where heterosexual HIV transmission is
dominant (i.e., pattern I 1 countries as defined by the
WHO).
According to the Swiss Federal Office of Statistics,
850,000 (14%) of the 7 million Swiss population visited
a developing country in 1996.8 It can be assumed that
some 17,000 (2%) of these tourists had unprotected
casual sex.9-" Recent estimates indicate that among
Swiss males aged 17 to 45, at least 25,000 had casual sex
with previously unknown partners while abroad, a large
proportion without condom protection.' Furthermore,
it can be assumed that only a minority of the so-called
sex tourists would perceive themselves as such and would
Tourism is increasingly recognized as an important
field for human immunodeficiency virus (HIV) transmission and prevention.',2 Although the number of new
HIV infections has not increased in Europe and the
USA in past years, recent reports from the World Health
Organization (WHO) estimate that approximately 30 million adults worldwide are infected with HIV,"' 94% of
them living in developing countries. Some regions with
Thomas M. Gehring, PhD and Jeanneite Widmer, MA:
University of Zurich, Institute for Social and Preventive
Medicine, Division of Health Promotion and Evaluation,
Sumatrastrasse 30, CH-8006 Zurich, Switzerland; Dieter
Kleiber, PhD: Professor of Sociology; Free University of
Berlin, Institute for Prevention and Health Research,
HabelscherdterAllee 45, D-14195 Berlin, Germany; Roberf
Steffen, MD: Professor ofTravel Medicine; University of
Zurich, Institute for Social and Preventive Medicine, Travel
Clinic, Division of Epidemiology and Prevention of
Communicable Diseases, Sumatrastrasse 30, CH-8006
Zurich, Switzerland.
This research was supported by a grant from the Swiss
Federal Office of Public Health.
This paper was presented at the Sixth Munich Conference on
AIDS, Munich, Germany, July 4-7. 1997.
Reprint requests: Thomas M. Gehring, PhD: ISPM,
Sumatrastrasse 30, CH-8006 Zurich, Switzerland.
JTravel Med 1998; 5:205-209.
205
206
report that they intended to pay for sex with previously
unknown partners. More important, one third of these
tourists mention that they never use condoms or use them
inconsistently. Studies of British, Scandinavian and Canadian travelers show a rate of approximately 5% of casual
sex among travelers to developing countries; those residing in Quebec had almost twice the rate of those living
in Ontario (Tessier and Keystone, personal communication). A recent study among German-speaking tourists
in Thailand indicated that only 30% of men who had
casual sex with Thai women used condoms reg~darly.~
Compared to male tourists, women have less casual sex
but they do not differ from men regarding safer sex
practices.jJoJ2
In recent years, HIV prevention in Switzerland was
focused on tourism since it was known that tourists may
exhibit risky sexual behaviors. The HIV prevention project ”Check-in Health” carried out at Zurich International Airport was developed with the primary goal to
provide information regarding safer sex rules to increase
the travelers’ awareness of sexual risk situations, and to
motivate the target groups to act according to safer sex
guidelines. In order to approach departing travelers,they
were invited to participate in a quiz including four questions about health and HIV/AIDS. The answers were
reviewed and discussed by health professionals. The
intervention consisted of a brief personal conversation
about casual sex and condom use before boarding. All
departing passengers, whether or not they participated
in the project, received brochures on sexual and healthrelated travel issues as well as condoms.
The present study was designed to determine the
impact of “Check-in Health” on casual sex and condom
use among the tourists. Three main questions were
addressed: First, do participants appreciate the intervention? Second, does the intervention have an impact on
planned and effective sexual behavior? Third, what are
the characteristicsof travelers who reported that they had
casual sex during their journey?
Method
This cross-sectional study run from November 1996
to April 1997 is based on a 2 X 2 control group design.
Volunteers were German-speaking departing and returning flight passengers at Zurich Airport with destinations
in pattern I1 countries aged 16 years and more. The passengers were approached by trained staff and invited to
complete an anonymous, self-administered questionnaire consisting of 24 items. The items for departing passengers were formulated prospectively (i.e., planned
behavior) and those for arriving passengers retrospectively
(i.e., effective behavior). The questionnaire addressed
J o u r n a l o f T r a v e l M e d i c i n e , V o l u m e 5, N u m b e r 4
the following issues: sociodemographic data, destination, duration and type ofjourney, number of previous
visits to the country in question, evaluation of the HIV
intervention, knowledge about HIV/AIDS, planned and
effective sexual encounters, use of condoms and subjective theories about sexual risk behavior.
Among 5,536 approached passengers, 3,100 German-speahng subjects (56%) agreed to participate in the
study. The sample consisted of 1,689 (54.5%) departing
passengers and 1,411 (45.5%) returning passengers. Travel
destinations included Kenya (24.5%), India (19.4%),
Thailand (17.5%), the Dominican Republic (18.0%),
Maldives (14.6%), Brazil (4.8%) and others (1.2%).
In order to examine the effects of the intervention
on planned and effective behavior and its evaluation by
the participants, we divided the study population into four
subsamples: 41 8 departing passengers who participated
in the intervention and 443 returning passengers who
remembered that they had participated in the intervention. The control group included 744 departing passengers and 848 arriving passengers who indicated correctly
that there was no intervention when their flight departed.
The remaining 548 passengers who were unable to recall
as to whether or not there was an intervention and those
99 passengers who refused to participate in the intervention had to be excluded.
The four subgroups did not significantly differ
regarding socioeconomic status, nationality (92% Swiss,
8% other), gender (49% male, 51% female), partnership
status (79% steady relationship, 21% single), age (mean
43.5 years), the purpose of the trip (90% holiday, 10%
business) and the duration of stay (94% from two to three
weeks). Two thirds of the respondents traveled together
with their steady partner, and halfof the sample were visiting the country for the first time.
Since cross-sectional data was used, the influence of
the intervention could only be analyzed indirectly (i.e.,
differences between the intervention and control group).
Data analysis was completed using SPSS and included c h square analysis and Mann-Whitney U-Tests.
pesults
Evaluation of the Intervention by the Participants (n = 861)
Ninety-four percent of the participants (n = 81 1)
rated the HIV intervention as important and 54.1% of
the participants (n = 466) indicated that they had gained
important information about health issues. Whereas
215 among the 418 departing subjects (51.4%) reported
that they intended to discuss HIV/AIDS with other travelers, only 164 among the 443 arriving subjects (37%)
indcated that they had actually done so during their journey (z = -4.61, p < ,001). Similarly, there were significantly more departing passengers than arriving ones who
G e h r i n g e t al., E v a l u a t i o n of H I V P r e v e n t i o n a t t h e A i r p o r t
attributed a behavior modification effect to the intervention (n = 119,28.4% vs n = 51, 11.5%, z = -6.39,
p < .001).
Comparison of the Four Groups (n = 2453)
Ninety-three percent ofthe respondents (n = 2274)
rated their knowledge on HIV/AIDS as good or even
very good. Whereas there was no significant difference
between the intervention and the control groups, departing passengers judged their knowledge as better than
returning passengers (z = -2.17, p < .05, intervention
group and z = -2.92, p < .05, control group).
A great majority of the respondents (n = 2294,
93.5%) knew that condom use is the cornerstone ofsafer
sex. Respondents of the intervention group reported more
often than those of the control group (n = 468/861,
54.3% vs n = 567/1592, 35.6%) that condom use is a
“very secure”protection method (z = -5.59, p < .001,
in departing passengers and z = -4.47, p < .001, in
arriving passengers).
Respondents who participated in the intervention
were more likely to know details about HIV/AIDS than
those of the control group (n = 652/861, 75.7% vs
n = 753/1592,47.3%, z = - 2 . 9 1 , ~< .01). In addition,
in the intervention group departing passengers responded
more often correctly to the respective item than the
arriving ones (n = 344/418, 82.3% vs n = 308/443,
69.5%, z = -2.01, p < .05).
Figure 1 shows the reasons for unsafe casual sex as
reported by departing and arriving passengers of the
intervention and control group. In general, the four
1 Interwenlion group
%
n Control group (departure)
B Intervention group (arrival)
80
n Control group (arrival)
$
s
$
g
Figure 1 Reasons for unsafe casual sex as reported by the
four groups In = 2453).
207
groups weighed the nine reasons for sexual risk behavior similarly. The categories “alcohol,” “corhdence/love”
and “lessjoy” were mentioned most frequently. Departing passengers who participated at the intervention mentioned all categories, except those of “alcohol” and
“love/confidence,” more often than their counterparts
(p < .05). Arriving members of both groups had a tendency to mention ”confidence/love” more frequently
than departing passengers (p < .05).
Table 1 shows the pattern of casual sex and condom
use as reported by the four subsamples. There were significant differences between planned and effective behavior. An intervention effect was found only for the planned
casual sex, whereby departing passengers of the intervention group were more likely than those of the control group to indicate that they could imagine having
casual sex with previously unknown partners. Whereas
departing passengers mentioned such a possibility relatively often, only a small minority of returning passengers reported that they really had casual sex. Although
most of departing passengers indicated that they would
use condoms consistently, only half of the subjects who
had casual sex reported that they had actually used them,
Table 1 Reported Casual Sex and Condom Use by
Departing and Arriving Passengers as a Function of
Intervention (n = 2453)
Intervention
and Sexual
Behavior Time
Departure
blamed
behaviov)
n
(%)
Intervention Group (1)
Casual sex (CS)
No
312 (74.6)
Yes
93 (22.3)
No answer
(13) (3.1)
Condom use (CU)
Consistent
86 (92.5)
Inconsistent
5 (5.4)
No answer
2 (2.1)
Control Group (2)
Casual sex (CS)
No
615 (82.6)
Yes
118 (15.9)
No answer
11 (1.5)
Condom use (CU)
Consistent
106 (89.8)
Inconsistent
9 (7.6)
No answer
3 (2.6)
Intervention Effect*
1 vs 2 (CS)
1 vs 2 (CU)
8.13t
n.s.
Arrival
(effective
behavior)
n (“A)
Time
Effect*
414 (93.5)
26 (5.8) 50.69’
3 (0.7)
17 (65.4)
6 (23.1)
3(11.5)
9.56t
769 (90.7)
60 (7.1) 30.25t
19 (2.2)
26 (43.3)
27 (45.0) 40.06*
7(11.7)
n.s.
n.s.
*Chi-square analysis, :p < .01,*p < ,001, n.s. = not significant
J o u r n a l of T r a v e l M e d i c i n e , V o l u m e 5, N u m b e r 4
208
Table 2
Differences between Travelers with and without Casual Sex (CS)
~~
Arriving Passengers
With CS
(n = 93)
Without CS
(n = 1288)
Variable
n
%
n
Male
59
Single
Destination Thailand
Duration of stay > 3 weeks
Number of visits in this country > 10 times
Traveling without partner
54
(63.4)
(58.1)
(17.2)
(29.0)
5.57
179
86
124
16
27
13
71
(14.0)
(76.3)
48
361
%
(44.2)
(13.9)
(6.7)
(9.6)
(3.7)
(28.0)
Chi-square*
16.02*
125.61
22.67t
36.28t
22.86t
131.18t
*Chi-square analysis,+p < .Ol,’p < .001.
and no significant effect of the intervention could be
found for the application of safer sex rules during the
journey.
Differences between Participants
and Nonparticipants (n = 517)
Only a small minority of the approached tourists
(n = 99/517, 19.2%) refused to participate in the preventive HIV interventions (i.e., quiz and consultation).
They differed significantly from departing participants in
five aspects: they knew fewer details about HIV/AIDS
(60.2% vs 84.3%, p < .001), reported more often inconsistent condom use (20.8% vs 5.5%, p < .05) and were
less motivated to speak about health-related issues (26%
vs 53.1%, p < .001),they evaluated health interventions
more often as irrelevant (19% vs 5.3%, p < ,001) and
believed less frequently that such interventions could have
an impact on their traveling behavior (17.8% vs 29.2%,
p < .05).
Characteristics of Tourists with Casual Sex
Among the 1,428 returning passengers, 1381 (96.7%)
answered the question whether or not they had had
casual sex during their journey. Because subjects of the
intervention and control group did not dffer significantly
the two subsamples were collapsed. Table 2 shows the differences between returning passengers who reported
casual sex and those who did not. In particular, passengers (n = 93,6.7%) who had casual sex were more likely
to be male and single; Thailand was a frequent destination; they stayed more than three weeks abroad and,
they traveled significantly more often without a stable
partner.
Sexual Risk Behavior
Women reported causal sex less often than men
but they were somewhat more likely than men to indicate
inconsistent condom use (13/30,43.3% vs 21/59,35.6%).
Compared to others, married persons indicated casual sex
less often, but they reported inconsistent condom use
more often (9/14, 64.3% vs 26/66, 39.4%). Furthermore, travelers over sixty years showed inconsistent condom use more frequently than those younger than thirty
(6/9,66.7% vs n = 5/20,25%). Finally, tourists who visited India (Goa) mentioned sexual risk behavior more
frequently than those returning from Thailand (12/20,
60.0% vs 3/16, 18.8%).
Travelers who indicated unprotected casual sex differed significantly in their reports on reasons for sexual
risk behavior from those who used condoms consistently. Respondents who showed unsafe behavior mentioned “spontaneity” or “no condom available” more
often than their counterparts (z = -2.27, p < .05 and
z = -2.21, p < .05 respectively) and “lack of knowledge”
less often (z = -2.19, p < .05) as reason for inconsistent
condom use.
Discussion
This cross-sectional study focused on departing
aQd returning tourists at Zurich Airport with destinations in pattern I1 countries. Two thirds of the respondents traveled together with their steady partner. The
presented data show that travelers are usually very well
informed about HIV/AIDS and that they appreciate the
intervention predominantly as positive and useful. For
example, more than one third of the returning passengers who had participated in the intervention reported
that they had discussed HIV/AIDS with others during
their journey, and every tenth respondent indicated that
the intervention had had a modifying effect on their
behavior. Although most people stated that they are
familiar with safer sex guidelines, significant effects of
209
Gehring et al., Evaluation o f H I V Prevention a t t h e Airport
the intervention could be revealed. In particular, the
members of the intervention group showed a more
detailed knowledge on HIV/AIDS and rated the use of
condoms more often than their counterparts as very
important. This provides evidence for the health-related
relevance of such interventions.
In contrast, the passengers who explicitly did not
want to participate at the preventive consultation indicated that they do not use condoms consistently for
casual sex. Thus, an important target group was not
reached by the intervention.
Comparisons on casual sex and condom use revealed
significant differences between planned and effective
behavior (i.e., time effect), and between the intervention
and control group (i.e., intervention effect). First, convergent with other studies, departing respondents of
both groups anticipated casual sex contacts relatively
often, also indicating to plan consistent condom use.2 Second, respondents who participated in the intervention
mentioned that they could imagine having casual sex
more often than those of the control group. It can be
assumed that the willingness of travelers to speak about
sex is likely to be increased in the context of such a preventive action. However, this research did not show an
impact ofthe intervention on the actual behavior. In other
words, arriving passengers of the intervention and control group who reported that they had had casual sex did
not differ regarding the use of safer sex rules.
Only a small minority consisting predominantly of
men, reported that they had had casual sex with previously unknown partners in the country visited. Convergent with other research, those who did form new
sexual liaisons were more likely to be single,to travel alone
and to stay more than 3 weeks abroad.'' Notably, nearly
half of these tourists indicated that they did not use
condoms consistently,thereby placing themselves at risk
for HIV infection. They tended to perceive these contacts as romantic encounters, a fact which hinders responsible sexual b e h a ~ i o r . ~Although
,'~
the results of our
study are convergent with other research,'.'' it may be
assumed that because of social desirability,the real number of unprotected sexual encounters has not been
revealed.
In conclusion, preventive HIV interventions at the
airport are a feasable way to approach tourists to pattern
I1 countries. However, although the travelers included in
the study appreciated the preventive HIV consultations,
they did not use condoms more consistently than those
in the control group. Future projects should aim to have
a greater impact and to better reach the small group of
travelers with low motivation for safe casual sex.
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