Duncan, Jacqueline MD, MPH*; Gebre, Yitades MD, MPH, MSc†; Grant, Yoran PHD (abd), MPH‡; Wedderburn, Maxine BSc§; Byfield, Lovette MSc¶; Bourne, Deborah MA§; Brown, Marsha MSc¶; Figueroa, J. Peter MBBS, DPH, PHD∥
The HIV epidemic in Jamaica has features of both a generalized and concentrated epidemic with an HIV prevalence of 1.6% in the general adult population, 25% to 30% among men who have sex with men and 3.6% among crack/cocaine users.1 Overall, about 27,000 persons are HIV infected with two-thirds unaware of their status. All 14 parishes in Jamaica are affected by the HIV epidemic, but the most urbanized parishes have the highest cumulative number of AIDS cases (St. James–992 AIDS cases per 100,000 persons and Kingston and St. Andrew–697 cases per 100,000 persons in 2007).2
Despite the establishment of a National HIV/STI program in 1986, early sexual debut, multiple sex partners, sex with prostitutes, and crack/cocaine use coupled with poverty continue to fuel the spread of HIV.3,4 In 2006, approximately 25% of persons living with AIDS reported “sex with prostitutes” as a risk factor and one-half of persons living with AIDS having a history of sexually transmitted infections (STI). Despite the vulnerability of sex workers (SWs) to HIV, data on this group in Jamaica and other Caribbean countries are limited posing a challenge to programme planning. A 2001 survey of SWs in Jamaica reported inconsistent condom use, alcohol and crack/cocaine use as high-risk behaviors in this population.5 However, HIV testing was not conducted and the relationship between behaviors and HIV status has not been determined.
A clear understanding of the epidemic in at risk groups and the behaviors that put them at risk is critical to achieving the Millennium Development Goals to reverse and halt the epidemic by 2020.6 A survey of SWs was conducted to determine HIV prevalence estimates and risk behaviors among SWs in Jamaica and guide programme planning.
MATERIALS AND METHODS
A cross-sectional study of female SWs was conducted in 2005 in 5 parishes in Jamaica: Kingston and St. Andrew (KSA), St. Catherine, St. James, Westmoreland, and St. Ann. These parishes account for 80% of all reported AIDS cases in Jamaica between 1982 and 2002. A basic 2-stage sampling design was employed. Step 1 entailed a social mapping of the sites where sufficient numbers of SWs could be regularly accessed. Potential sites were identified by key informants including outreach officers of Jamaica AIDS Support, SWs peer educators, contact investigators, and behavior change communication officers of the National HIV/STI Program (NHP).
A list of the sites and size measurement by day of week and optimal time of day was generated. These time-location units formed the primary sampling units in a comprehensive sampling frame.
Step 2 involved random selection of sites from the sampling frame for each area. Convenience and snowballing sampling were used to identify participants at each site. Questionnaires were administered by face-to-face interviews to all participants and blood drawn for HIV rapid testing. The questionnaire was a modification of the core instrument contained in the Family Health International behavioral surveillance survey manual. Topics included condom use, knowledge of STIs, and exposure to HIV prevention activities. Data were collected late nights and early mornings at the sites by trained interviewers. Interviewers operated in teams, accompanied by a field supervisor to facilitate on the spot problem solving.
All participants received pretest and posttest counseling for HIV testing consistent with international standards with samples drawn by phlebotomists. Blood samples were tested on site using Determine HIV rapid tests, and participants were informed of the results at the interview site. Positive samples were sent for confirmatory testing (Western Blot) at the National Public Health Laboratory and participants with positive results were referred to the nearest clinic for results. Unique participant numbers were assigned by interviewers to each questionnaire, providing a link to blood samples. Names, addresses, and telephone numbers were recorded by phlebotomists and participants who had a confirmed positive result were contacted by a contact investigator for follow-up. SWs who were unwilling to participate in both the behavioral survey and biologic testing were excluded from the study.
The study was approved by the Ministry of Health's ethical review committee.
Analyses were done using SPSS version 15.0 and SAS version 9.1.3. Respondents were classified by HIV status and comparisons between groups were performed using chi-square for proportions and Student t test for continuous variables. Fisher exact tests were used for tables with sparse data. Multivariate logistic regression was used to examine associations between independent variables and HIV status. After identifying statistically significant variables, backwards elimination was used to design the final model.
Demographics, Education, and Work
About 450 SWs participated in the survey. The mean age was 26.8 years, and the mean age of first commercial sex activity was 18.7 years. Overall, 9% of SW participants were found to be HIV-positive. There was no significant difference in age of first commercial sex between HIV-positive SWs and HIV-negative SWs (19.4 vs. 18.7 years, P = 0.44), but HIV-positive SWs tended to be older and had fewer years of education (Table 1).
Most participants (58.0%) had a regular nonpaying partner, and 21.6% of all respondents were married or living with a partner. HIV-negative SWs were not more likely to report being married or living with a partner than their HIV-positive counterparts (21.9% vs. 17.9%, P = 0.567). The majority of SWs (98.6%) had formal education with secondary level education being the highest level of education attained in 83.6% of cases and a minority (2.5%) received tertiary education training. Sex work was the sole job held by most SWs interviewed (70.4%).
Mobility was common among participants interviewed outside of the capital parish as more than 50% of these participants resided outside of the parish that they were interviewed and working.
HIV/STI Knowledge, and Attitudes
All participants were aware of HIV and most SWs reported taking actions to protect themselves from HIV primarily by using a condom. HIV knowledge was assessed by the respondents' recognition of ways to prevent HIV transmission (consistent condom use and having 1 faithful partner), rejection of common myths (HIV transmission by mosquito bites and meal sharing), and agreeing that a healthy looking person can have HIV infection. Most SWs agreed that consistent use of condoms (98.2%) and having 1 faithful uninfected partner (74.0%) were appropriate ways to protect oneself from being infected with HIV. However, less than half (38.6%) of SWs appropriately rejected misconceptions about HIV transmission (Table 2).
Accepting attitudes to persons living with HIV (PLHIV) was measured by appropriate response to 3 questions: should a HIV-positive teacher be allowed to continue teaching, would you be willing to buy food from a HIV-positive shop keeper, and would you be willing to care for a sick HIV-positive family member. Overall, few (36.4%) SWs showed accepting attitudes toward PLHIV, and this was independent of HIV status. Only 42% of SWs would be willing to buy produce from an HIV-positive vendor. Attitudes were more accepting for HIV-positive teachers, with 65% agreeing that HIV-positive teachers should be allowed to teach.
Sexual Behavior and Condom Use
The mean number of sex partners in the last 7 days was 3.6 and HIV-positive SWs reported having more regular paying partners in the last 7 days compared to HIV negative SWs (3.7 vs. 1.9, P = 0.07). Overall, condom use at last sex with nonpaying partners was significantly less than condom use with paying partner (30.0% vs. 91.3%, P = 0.003). Both condom use at last sex with nonpaying partner and consistent condom use were also reported less frequently by HIV-positive SWs compared to HIV-negative SWs (Table 3). An assessment of condom use with different client types indicated that condom use at last sex with paying partner did not differ by client type (tourist client 96.0%, local client 92.4%).
The decision to use condoms during sex was primarily self-made (73.1%) and to a lesser extent, a joint decision (22.4%). The main reasons cited for condom nonuse were partner objection and not thinking it was necessary.
Over 80% of SWs had condoms on hand and 98.2% of SWs reported access to condoms within 5 minutes of their place of work. This was similar for HIV-positive and HIV-negative SWs. Female condom use was low, however, and HIV-positive SWs were more likely to report use of a female condom than HIV-negative SWs (69.2% vs. 38.8%, P = 0.037) (Table 3).
Sexually Transmitted Infections
A significantly larger proportion of HIV-positive SWs reported ever having a STI (Table 2). Additionally, HIV-positive SWs were more likely to do nothing about their STI than their HIV negative counterparts (40% vs. 2.2%, P = 0.013). While most SWs reported ever having an HIV test (76.6%) and knowing their HIV status (83.7% of those tested) before the survey, 43% had an HIV test within the past year and voluntary HIV testing did not vary significantly between HIV-positive and HIV-negative SWs (63.6% vs. 76.8% P = 0.162). HIV-positive SWs were significantly less likely to be aware of the NHP's safe sex programs (25.6% vs. 63.7%, P < 0.0001). More than 90% of SWs expressed a desire to have regular check-ups (Table 4).
Everyday alcohol use was reported by more than half of SWs (58.6%) and lifetime marijuana use was reported by 56.6% of respondents. Crack/cocaine use was significantly greater among HIV-positive SWs (27.6% vs. 4.1%, P < 0.001). HIV-positive SWs were also more likely to smoke cigarettes (86.8% vs. 69.6%).
Correlates of HIV Infection
Multivariate logistic regression analyses demonstrated that age, crack/cocaine usage, lack of condom use at last sex with paying Jamaican client, and lack of knowledge of the NHP's safe sex program were significantly associated with HIV infection. Specifically, SWs who had used crack/cocaine were eight (8) times more likely to be HIV-positive. The odds of HIV infection increased 47% with each 5-year increase in age, suggesting that older SWs were more likely to be HIV-positive. SWs who reported condom use at last sex with paying Jamaican client were 76.5% less likely to be HIV infected. Being aware of the NHP's safe sex program also reduced the odds of HIV infection by 76%.
This survey confirms the findings of a 2001 behavioral survey of SWs in Jamaica and provides additional insight into the SW population. In this cross sectional survey, 9% of SWs were HIV-positive. This is significantly lower than a previous survey which reported a prevalence of 25% among Jamaican SWs.7 However that survey was restricted to one city in Jamaica and recruited a smaller number of participants. Both surveys relied on convenience sampling and may be an underestimate of the epidemic in this population since persons who are most at risk may have declined participation or HIV testing.
The survey confirms that the high-risk behaviors of Jamaican SWs include multiple sex partners (mean = 3.06), inconsistent condom use, and substance abuse (alcohol and crack/cocaine). These high-risk behaviours tend to be greater among HIV-positive SWs and SWs who were not exposed to a MOH programme. This reinforces the need to expand prevention programmes targeting SWs as studies suggest that prevention programmes can result in significant increases in condom use in sexual partnerships of SWs.8–10
In this survey, SWs reported having easy access to condoms and condom use was generally high. This high level of condom use may be due to reporting bias as interviewers identified themselves as Ministry of Health representatives and participants may not have answered honestly in order to impress interviewers. This may also explain the discrepancy in reported condom use with paying partners and the high level of STIs reported by SWs within the last 12 months.
However, condom use at last sex with nonpaying partner was significantly lower than condom use with paying partner. Similar findings of higher condom use with paying partners was found in a previous of SWs in Jamaica in which 92% respondents used condoms at last sex with nonpaying partners compared to 43% with paying partners.5 Behavioral surveys of SWs in other countries have also found low condom usage with nonpaying partners who often have multiple partners and high HIV prevalence.11–14 This has implications for prevention programmes since many studies on interventions with SWs have shown significant increases in condom use in paying partnerships only.15,16 Risk reduction messages and interventions targeting SWs will require novel approaches that address condom use in the various types of partnerships of this group. HIV counselling and testing for couples is one such strategy that has been shown to reduce risk behaviors and decrease seroconversion in serodiscordant couples.17,18
Prevention programmes must maintain the high level of knowledge about HIV prevention while reducing myths as HIV/STI knowledge is an important determinant of condom use19 and may reduce stigmatization of PLHIV. Although 97% of SWs were able to identify at least 1 way to prevent HIV correctly, only 38% could reject some of the more common myths. This is similar to the findings of a 2001 SW survey and a national survey.20
Self efficacy also has a direct effect on condom use and is an important mediator between HIV/STI knowledge and condom use.21 In our survey, the majority of SWs reported that they decided when to use a condom and nonuse was often due to no perceived risk. An HIV vaccine preparedness study in the Caribbean demonstrates the inability of persons to identify risky sexual behavior.22 More than 50% of the recruited high-risk persons did not perceive themselves as being at risk for HIV infection. This finding reinforces the need for a shift in strategy from general prevention messages to inclusion of intensive individual risk reduction counselling. Future surveys need to explore the role of other determinants of condom use such as perceived benefits of unprotected sex and perceived support for condom use among Jamaican SWs.21
This survey has several limitations. First, we relied on informants to identify SWs sites and used convenience and snowball sampling. Therefore, some SWs sites may not have been included and these may have included persons at highest risk for HIV.
The survey also relies on self reported behavior, which may result in recall bias and socially desirable responses, which were not confirmed using biologic testing. Use of biologic markers to confirm behaviors such as condom use and STI prevalence in future studies will enhance the reliability of the data.
Finally, the possibility of different behaviors among SWs in 1 area versus another (e.g., tourism areas) should be considered in planning interventions and directing resources.
HIV prevention is a priority for the national HIV/STI programme in Jamaica. Prevention strategies targeting SWs must aim to increase HIV prevention knowledge, reduce commons myths, promote self-assessment of risk, and explicitly encourage condom use with nonpaying partners. A variety of strategies may be necessary to achieve the desired behavior change.
1. Ministry of Health. National HIV/STI Programme, Jamaica Country Progress report January 2006–December 2007. Jamaica: Ministry of Health, 2008.
2. Ministry of Health. National HIV/STI Prevention & Control Programme Facts and Figures HIV/AIDS Epidemic Update January to December 2007. Jamaica: Ministry of Health, 2007.
3. Norman LR, Figueroa JP, Wedderburn M, et al. Trends in HIV risk perception, condom use and sexual history among Jamaican youth, 1996–2004. Int J Adolesc Med Health 2007; 19:199–207.
4. Figueroa JP. Overview of HIV/AIDS in Jamaica: Strengthening the Response. West Indian Med J 2004; 53:277–282.
7. Douglas KG, Brathwaite A, Patterson V, et al. International Conference on AIDS. Risk factors associated with STD/HIV seropositivity among female commercial sex workers (CSWS)–implications for an integrated intervention strategy. Int Conf AIDS 1996; 11:347. Abstract Tu.C. 2477.
8. Laukamm-Josten U, Mwizarubi BK, Outwater A, et al. Preventing HIV infection through peer education and condom promotion among truck drivers and their sexual partners in Tanzania, 1990–93. AIDS Care 2000; 12:27–40.
9. Leonard L, Ndiaye I, Kapadia A, et al. HIV prevention among male clients of female sex workers in Kaolack, Senegal: Results of a peer education program. AIDS Educ Prev 2000; 12:21–37.
10. Ray S, Van De Wijgert J, Mason P, et al. Constraints faced by sex workers in use of female and male condoms for safer sex in urban Zimbabwe. J Urban Health 2001; 78:581–592.
11. Kayembe PK, Mapatano MA, Busangu AF, et al. Determinants of consistent condom use among female commercial sex workers in the Democratic Republic of Congo: Implications for interventions. Sex Transm Infect. 2008; 84:202–206.
12. Stulhofer A, Brouillard P, Nikolić N, et al. HIV/AIDS and Croatian migrant workers. Coll Antropol. 2006; 30(suppl 2):105–114.
13. Xu JJ, Wang N, Lu L, et al. HIV and STIs in clients and female sex workers in mining regions of Gejiu City, China. Sex Transm Dis 2008; 35:558–565.
14. Lowndes CM, Alary M, Gnintoungbé CA, et al. Management of sexually transmitted diseases and HIV prevention in men at high risk: targeting clients and non-paying sexual partners of female sex workers in Benin. AIDS 2000; 14:2523–2534.
15. Alary M, Mukenge-Tshibaka L, Bernier F, et al. Decline in the prevalence of HIVand sexually transmitted diseases among female sex workers in Cotonou, Benin,1993–99. AIDS 2002; 16:463–470.
16. Walden VM, Mwangulube K, Makhumula-Nkhoma P. Measuring the impact of a behaviour change intervention for commercial sex workers and their potential clients in Malawi. Health Educ Res 1999; 14:545–554.
17. Painter TM. Voluntary counseling and testing for couples: a high-leverage intervention for HIV/AIDS prevention in sub-Saharan Africa. Soc Sci Med 2001; 53:1397–1411.
18. Desgrées-du-Loû A, Orne-Gliemann J. Couple-centred testing and counselling for HIV serodiscordant heterosexual couples in sub-Saharan Africa. Reprod Health Matters 2008; 16:151–161.
19. Oladosu M. Consistent condom use dynamics among sex workers in Central America: 1997–2000. J Biosoc Sci 2005; 37:435–457.
20. Hope Enterprises Limited. Knowledge, Attitudes, Beliefs, and Practices Survey-2004. Jamaica: Hope Enterprises Limited; 2005.
21. Wang B, Li X, McGuire J, et al. Understanding the dynamics of condom use among female sex workers in China. Sex Transm Dis 2009; 36:3.
22. Djomand G, Metch B, Zorrilla CD, et al. 903 Protocol Team: The HVTN protocol 903 vaccine preparedness study: Lessons learned in preparation for HIV vaccine efficacy trials. J Acquir Immune Defic Syndr 2008; 48:82–89.