The global literature indicates an important role of alcohol use in facilitating HIV/AIDS transmission risk in commercial sex venues where elevated alcohol use/abuse and sexual risk behaviors frequently co-occur. Because the relationship between alcohol use and sexual risk behaviors in commercial sex venues results not only from individual attributes (personal knowledge, attitudes, and skills), but also from complex interactions among individual, relational, situational, and social environmental factors, there is a need for intervention approaches that extend beyond the individual level and address structural or community level factors. Although structural-level changes (e.g., legislation, governmental policy) regarding commercial sex have demonstrated considerable success in effecting sustainable risk reduction among female sex workers (FSWs) and their clients in several nations, the introduction of such changes remains challenging in many nations including China. In these later countries, local-level, establishment-based approaches may be needed to curtain the interrelated epidemics of alcohol use and HIV/STD among this high risk population before broader structural changes become feasible. Previous studies in Asia and Africa and our own data from FSWs in China suggest that the social norms and institutional policy within commercial sex venues as well as agents overseeing the FSWs (i.e., the "gatekeepers", defined as persons who manage the establishments and/or sex workers) are potentially of great importance in influencing alcohol use and sexual behavior among establishment-based FSWs. Therefore, in this application, we propose to develop, implement, and evaluate a venue- based alcohol use and HIV risk reduction intervention focusing on both environmental and individual factors among venue-based FSWs in China. The proposed venue-based intervention consists of three components: (1) gatekeeper training with a focus on changing or enhancing the protective social norms and policy/practice at the establishment level;(2) FSW training with a focus on the acquisition of communication skills (negotiating, limit setting) and behavioral skills (e.g., condom use skills, consistent condom use);and (3) semi-annual boosters to reinforce both social norms within establishments and individual skills. The efficacy of the venue-based intervention will be evaluated through a community-based cluster randomized controlled trial among 100 commercial sex venues in Beihai, a costal tourist city in Guangxi, China. We anticipate that the venue-based intervention program will be culturally appropriate, feasible, effective and sustainable in alcohol use and sexual risk reduction among FSWs. We hypothesize that the venue-based intervention will change and enhance the protective social norms and institutional policies at the establishment level and such enhancement, accompanied by individual skill training among FSWs, will demonstrate a sustainable effect within commercial sex establishments in decreasing problem drinking and alcohol-related sexual risk, increasing consistent and correct condom use, and reducing rates of HIV/STD infection among FSWs.
We propose a 5-year study to develop, implement, and evaluate a theory-guided, multiple components, and venue-based HIV and alcohol use risk reduction intervention among commercial sex workers (FSWs) in China. There are three main operational phases in this study. Phase One involves formative research to collect additional data regarding alcohol use/abuse and related sexual risk among FSWs in China through both rapid quantitative assessment and in-depth qualitative inquiries. These data will be supplementary to the existing data on sexual risk among FSWs we collected in our previous study among FSWs in China. Phase Two will focus on further modification, pilot-testing, and finalization of both the proposed intervention curricula and assessment tools. The proposed intervention program will be a cultural adaptation and integration of existing evidence-based programs in Asian settings. The additional modification efforts will be informed by the data we collected in Phase One. Phase Three includes the intervention delivery and evaluation through a venue-based cluster randomized controlled trial among 100 commercial sex venues (with about 150 gatekeepers and an open cohort of 700 FSWs) in Beihai, a coastal tourist city in Guangxi China. Serial behavioral and biomedical data from both gatekeepers and FSWs will be collected every 6 months over a 2-year period to assess the long-term impact of the intervention.
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