From 1998 to 2003, DFSWs reported a large increase in consistent condom use with clients, from 53.4% in 1998, to 78.1% in 1999, 91.7% in 2001, and 96% in 2003 (P < 0.0001). IDFSWs reported an even greater increase in consistent condom use with clients, from 29.7% in 1998 to 38.2% in 1999, 55.2% in 2001, and 84.4% in 2003 (P < 0.0001) (an increase of 55 percentage points). Figure 1 illustrates how condom use increased for both DFSWs and IDFSWs more with commercial partners than with sweethearts.
Across the 6 years (1997-2003), sex workers became older and conditions of sex work changed: DFSWs reported staying in their profession longer, stayed longer in each brothel, size of brothels increased, and more were tested for HIV (Table 1). For IDFSWs, significantly more reported practicing commercial sex in the past year (from 21% to 37%) and many more reported getting tested for HIV (from 21% to 70%) (Table 1). Finally, since 1998, respondents were asked if they know someone sick with HIV/AIDS, and these numbers increased considerably each year, from 7% to 64% among DFSWs and from 9% to 69% among IDFSWs (Table 1).
Condom use increased with both partner types over the 6 survey years (Fig. 1). DFSWs who worked longer in sex work, lived in larger brothels, had been in a particular brothel longer, did not have a sweetheart in the past year, never had been married, did not have abnormal vaginal discharge in the past year, and had been tested for HIV were significantly more likely to have reported always using condoms with clients in the past week than those who did not always use condoms (Table 2). DFSWs who reported a sweetheart in the past year compared with DFSWs who did not have such a partner were younger (22.3 vs 21.9 years, P = 0.008), had more clients in the last day (3.4 vs 2.7 men, P < 0.0001), were in smaller brothels (7.4 vs 8 other women, P = 0.004), spent a longer duration in that brothel (7.5 vs 6.7 months, P = 0.004), and had more years in sex work (1.8 vs 1.4 years, P < 0.0001).
As with DFSWs, with each successive survey, significantly more IDFSWs reported consistent condom use (P < 0.000) with both commercial and noncommercial partners (Fig. 1). Among IDFSWs reporting sex for money, those who were slightly older, had started sex later, had been sexually active longer, did not have a sweetheart in the past year, or had sex with a sweetheart in the past year, had vaginal discharge, were not from Battambang, and had an HIV test were more likely to report always using condoms with clients in the past 3 months than IDFSWs who did not always use condoms with clients (Table 2). Like DFSWs, those IDFSWs with sweethearts were more likely to be younger (22.4 vs 23.1 years) than those without sweethearts.
In the multiple regression models, DFSWs reported condom use with clients was significantly higher during later survey years (OR, 2.29 per year or per 4 years, as appropriate) and among those who were in larger brothels (OR, 1.02), and charged more for sex (OR, 1.29), but was lower for DFSWs with sweethearts (OR, 0.68) and those who reported abnormal vaginal discharge (OR, 0.50). In the adjusted models for IDFSWs, reported condom use with clients was higher in later years (OR, 1.80 per year or per 4 years as appropriate), among those who were tested for HIV (OR, 1.44) and lower for those with sweethearts (OR, 0.48) (Table 3).
Cambodia started an intensive monitoring and prevention program early in its HIV epidemic when the first evidence of high HIV prevalence among core groups became available. These findings demonstrate that, with each year, consistent condom use during commercial sex has increased among women working in the sex industry, that is, increases in condom use with clients from 53% to 96% for DFSWs and 30% to 84% for IDFSWs, suggesting intervention efforts by NCHADS, the Cambodian Ministry of Health, and nongovernmental organizations seem to have been effective especially in the groups practicing the most direct commercial sex. Continuing declines in HIV prevalence reported in the HSS further support this reported behavior change. Levels of behavior change can be compared with the first 3 years of Thailand's BSS (1993-1996), where increases in condom use during commercial sex among DFSWs were significant although small, 87% to 97%, and for IDFSWs, 56% to 89%.13 In addition, more sex workers reported consistent condom use with all types of partners: clients, regular clients, and even noncommercial partners (sweethearts).
These findings suggest that the Cambodian sex industry is in transition; sex workers seem to be staying longer in sex work and longer in each brothel and are older than 5 years earlier. Outside of the brothels, more IDFSWs are reporting that they sell sex. Such changes may translate into increasing competition among DFSWs for clients and increasing pressure among them to maintain clients. Many DFSWs report regular clients and noncommercial partners, and the DFSWs with the latter were less likely to use condoms consistently with their clients who are concurrent, perhaps as an attempt to convert them into regular or relational partners. These DFSWs may be concerned about aging and being outcompeted by younger women who can charge more for sex, which makes condom use more difficult to negotiate for older ones. DFSWs seeking a way out of sex work through a single partner may be cultivate regular clients and noncommercial partners (sweethearts) while they can still compete for such partners. Therefore, sex workers may be changing partners to change their behavior; a change in condom use behavior may represent the prelude to an exit out of sex work because decreasing condom use may be an attempt to seek and keep the partners who will help women leave the sex industry because sex without condoms is often interpreted as an expression of intimacy and trust. The findings also suggest that among IDFSWs, noncommercial, casual sex is on the rise.
DFSWs may be moving out of brothels that increasingly carry a stigma of high HIV risk into venues such as karaoke bars or massage parlors where women work as IDFSWs under the guise of another profession. The finding that more IDFSWs reported selling sex each year may also be a sign of an increasing market for IDFSWs or a greater willingness among this group to disclose their risky behavior. IDFSWs represent a vulnerable group of women who need more aggressive interventions that are designed specifically for them regarding behavior change.
Other measures of the conditions of sex work suggest the potential for structural/environmental level change to influence individual sex worker behaviors. Women from larger brothels and those who charge more for sex are more likely to use condoms. These larger and more expensive brothels may be better managed and therefore may have personnel who enforce condom use, serving as backup for individual sex workers' requests for clients to use condom. Earlier research on brothel size in Cambodia suggested larger brothels were safer environments for women because lower HIV prevalence was noted in the larger ones compared with that in smaller ones early in the Cambodian HIV epidemic.19
DFSWs and IDFSWs who reported abnormal vaginal discharge in the past year were less likely to report condom use with clients. Although such discharge may have been a symptom of an episode of an STI and DFSWs infected with STIs would be more likely to transmit or acquire HIV, self-reports of discharge are poor markers of STI. Such discharge could also be a symptom of being HIV positive because women with HIV are more likely to experience vaginal discharge20 caused by both STI and non-STI pathogens. Either case suggests such women may represent high transmission risks, and that they are less likely to consequently use condoms suggests they are putting their partners at possible exacerbated risk of infection. Moreover, these symptoms may suggest that their lack of condom use may already have had consequences for them such as acquiring an STI and may represent their risk for acquiring HIV if they have not done so already, suggesting a need for STI services for DFSWs.
That IDFSWs who report being tested for HIV are more likely to use condoms during commercial sex than those not tested suggests a strong potential for HIV voluntary counseling and testing programs. Women who test for HIV individually are less likely to reduce unprotected sex with a primary or nonregular partner than women who test as part of a couple21; nevertheless, women who are at particular risk may be more likely to change their behavior than those in the general population. Although women who test for HIV may be those already predisposed to higher condom use because they tend to practice protective behaviors in general, the potential for voluntary counseling and testing as a strategy for behavior change among female sex workers in Cambodia needs exploration.
Cambodia's BSS provides evidence that HIV/AIDS prevention efforts have been successful and are rapidly transforming the risk profile of a population, potentially stalling the spread of HIV in the country. In response to behavior change programs for sex workers, increases in condom use have also been noted in Abidjan, Cote d'Ivoire,22 and Cotonou, Benin23 concurrent with reductions in STD and HIV prevalence, and much of the success of Thailand's decrease in HIV prevalence has been attributed to sex worker-focused interventions such as the 100% condom program.24 It should be mentioned that Cambodia has gone beyond behavior change in its HIV prevention efforts by implementing programs in sexually transmitted infection screening and treatment, enforcement of 100% condom policies in brothels, and expanded HIV testing, and such programs have most likely contributed as well to stemming the course of their HIV epidemic. In the face of increasing pleas for biologic prevention, Cambodia contributes to the growing body of evidence that the course of HIV epidemics can be altered by effective behavior change programs, and resources must be maintained to sustain such efforts.
We thank Hor Bun Leng for his support and Mun Phalkun, Seng Sopheata, Kao Chantha, and Theng Thithara of the Cambodian Ministry of Health and the NCHADS for their contribution to data collection and management.
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Keywords:Copyright © 2006 Wolters Kluwer Health, Inc. All rights reserved.
behavioral surveillance; Cambodia; HIV/AIDS; sexual behavior