Multiple Condom Use in Commercial Sex in Lamphun Province, Thailand: A Community-Generated STD/HIV Prevention Strategy

Background and Objective: In an investigation of condom breakage in commercial sex, we found a high proportion of multiple condoms use. This study sought to ascertain the characteristics of brothel-based commercial sex workers (CSWs) and their clients; to identify the decision makers (clients and/or CSWs) active in choosing multiple condom use; and to determine whether there is an implicit hierarchy of condom use negotiation.

Goals: To identify factors associated with multiple condom use in commercial sex and to provide an understanding of how this innovation developed in this setting.

Study Design: Sixty-seven brothel-based CSWs in Lamphun Province who participated in a study of condom breakage participated in a case-control study of multiple versus single condom use, which determined CSW and client characteristics for evidence of multiple condom use. Interviews and focus groups were used to determine decision making for condom use and the contexts for multiple use. Association between characteristics of CSWs/clients and multiple condom use was analyzed using X² for trend.

Results: No official program encouraged multiple condom use; this appeared to be a community-devised strategy to increase protection from human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs). CSWs working in daytime brothels had significantly greater multiple condom use than those working in nighttime brothels; mean percentages + SD of multiple simultaneous use were 57.5% + 28.6 and 35.5% + 22.4, respectively (p < 0.001). Day CSWs were older, had more pregnancies, reported higher frequency of STD symptoms and history of pelvic inflammatory disease, and had more clients per day but had a lower number of sex acts per client than night CSWs. Among factors associated with multiple condoms, only age was significant. The decision to use single or multiple condoms for a sex act was primarily (78.2% in single and 79.3% in multiple) made by the CSW herself. The main reason given for multiple condom use was protection from HIV/STD.

Conclusions: There is high compliance between CSWs in Lamphun province and the Ministry of Public Health - sponsored 100% condom use campaign, and CSWs are attempting to further reduce their risks of HIV/STD exposure by using multiple condoms for sex with their clients.

THE SEMIANNUAL sentinel surveillance program for HIV infection established by the Thai Ministry of Public Health in 1988 found the highest human immunodeficiency virus (HIV) seroprevalence among female commercial sex workers (CSWs) in the northern part of Thailand.^1,2 In 1991, the ministry adopted the "100% condom campaign" to promote safer sex in commercial sex establishments. Several studies have reported that condom use in commercial sex has increased to being nearly universal (100%).^3,4 During an ongoing study to evaluate the mechanisms of condom breakage in commercial sex in Lamphun Province in 1995, while examining used condoms, we found that for a high proportion of sex acts more than one condom had been used.^5,6

Of 5,040 total sex acts, a single condom was used for 2,485 (49.3%) sex acts. Of the 2,525 (50.1%) multiple condom use sex acts, 2,469 (98.4%) used double condoms at once, whereas three and four condoms were used for 53 (2.1%) and 3 (0.1%) sex acts, respectively.⁵ Multiple condom use significantly decreased the risk of potential exposure to HIV/sexually transmitted diseases (STD) by decreasing the probability of exposure breakage (all condoms used at a single time broke) from 1.8% to 0.2% (p < 0.001).⁶

Two kinds of sex establishments were included in the study: daytime and nighttime brothels. Previous studies of sex workers in Thailand have described "direct" versus "indirect" sex establishments,⁷ defined by whether sex is sold and occurs on the premises (direct, eg., brothels) or occurs elsewhere (indirect, e.g., bars, karaokes, restaurants). These categories are used by the Thai Ministry of Public Health in their sentinel surveillance for sex workers.⁸ We studied only direct brothel-based sex workers, but significant differences emerged between direct establishments based on hours of operation.

In this context, we explored the characteristics of CSWs and their clients in both types of brothels to identify factors associated with multiple condom use, to attempt to identify the decision makers (clients and/or CSWs) active in choosing multiple condom use, to examine reasons for using multiple condoms, and to determine whether there is an implicit hierarchy of condom use negotiation.

Subjects and Methods

Between August and October, 1995, 68 brothel-based CSWs working in seven establishments in Lamphun Province provided 7,594 used condoms for examination for evidence of multiple condom use. The reports of simultaneous multiple condom use of the CSWs were verified by finding, in many cases, that two (or more) used condoms were rolled up inside one another. During a 2-week period at the conclusion of the prior study, we interviewed 67 of the CSWs about the decision making for condom use and the contexts for multiple use; one of the original women was out of Lamphun during the study period. In this study, we conducted a nested case-control study of single and multiple condom use events. A projected sample size of 100 single use and 100 multiple condom use sex acts was predetermined to provide sufficient responses to investigate why multiple condoms were being used in this setting. For each instance of multiple condom use, a comparison with a single use occasion on the same day was determined, and the CSWs were then interviewed using structured questionnaires to determine characteristics of CSWs and clients associated with multiple condom use. Information on number of clients per day, number of sex acts per day, and order of clients was validated by daily coital logs recorded by CSWs.

Focus group discussions with CSWs were also conducted by two authors who were trained in focus group methods. This method was used to determine characteristics of CSWs and clients associated with multiple versus single condom use, to elicit factors associated with the adoption of this innovation, and to determine the hierarchy of condom use negotiation between CSWs and their clients. The focus groups lasted approximately 45 minutes and were conducted in privacy at the establishments. Two night brothels (of five) were selected based on convenience, and both day brothels were selected for participation in the focus group study, each of which employed six to seven CSWs. Dominant themes from the focus groups were documented by a review of the notes from the course of these sessions and were summarized by major topic areas.

Results

Overall, we documented 92 sex acts where a single condom was used and 88 events where multiple condoms were used. Although the projected number of occurrences was set at 100, we suspended the study in late October for administrative reasons. In a comparison between the 92 sex acts in which one condom was used and the 88 sex acts with multiple condoms, the initiation of condom(s) usage was usually made by the CSW rather than the clients. In single condom use 78.2% and in multiple condom use 79.3% of decision making of the number of condoms to be used was initiated by the CSW (p = 0.282). In most instances the CSW put the condom on her client; customers rarely put the condom(s) on themselves.

The main reason given for condom use was protection from HIV/STD, which was not different between single (88.0%) and multiple (89.7%) condom users (p = 0.574). The only other reason infrequently cited was pregnancy prevention (reported by seven CSWs).

Day brothels were those open only during daytime hours. Focus group discussions revealed that day brothel workers were older than night workers and that most were native lowland Thais earning their living as CSWs at their own discretion and choice. Several of these day brothel workers reported living with a regular partner. Virtually all were fully aware of the HIV situation in Thailand. The so-called "night brothel" sex establishments studied tended to have both younger workers and clients. Focus group discussions with these women suggested that many were less aware of the HIV epidemic and of how to best protect themselves from acquiring STDs and HIV. Multiple condom use was significantly more frequently reported by CSWs working in daytime compared with nighttime brothels; the mean percentage of multiple condom use in day CSWs was 57.5 + 28.6, whereas for night CSWs it was 35.5 + 22.4 (p = 0.001).

Daytime CSWs were significantly older, had more clients per day, and less frequently had more than one sex act per client than night CSWs (Table 1). They also reported a history of STD or pelvic inflammatory disease (PID) symptoms more frequently than night CSWs.

Table 1

Clients 30 years of age or older tended to use multiple condoms more frequently than their younger counterparts (p < 0.01). Condom use was not different whether clients were regular clients or drunk or infrequent clients at the time of the brothel visit (Table 2). No other factors approached statistical significance.

Table 2

The frequency of multiple condom use increased with the number of clients on the day of service. The order of service (first, second, or later client) was associated with use of two (or more) condoms. This was true for both day (X² for trend, p < 0.001) and night (X² for trend, p < 0.001) CSWs.

For the focus group study, all women approached in the four brothels consented to participate. Results from focus group discussions concerning client characteristics associated with number of condoms used at a time included the following factors: (1) characteristics associated with increased multiple condom use, which were older client age, larger penile size, and client's fang muk (surgical implantation of pearls or glass beads into the penile foreskin); (2) factors tending toward use of single condoms, which were perceived client cleanliness, high intensity of intercourse, and being a regular client; (3) factors associated with use either of single or multiple condoms, which included client drunkenness and anticipated long duration of intercourse.

We determined from the information obtained from focus group discussions that there was an implicit hierarchy of condom use negotiation. The majority of CSWs tended to propose using two condoms, and most of the clients agreed. Very few clients asked to use no condoms, and if they did, CSWs generally refused to have sex with them. A few clients asked to use only one condom. Very few clients asked for more than two condoms. CSWs reported in the focus groups that they did not like using more than two condoms because of pain associated with prolonged intercourse. We were not able to verify whether intercourse acts were longer when multiple condoms were used or any reports of vaginal irritation and pain.

Discussion

Although Thailand has had a very successful "100 % condom use program,"³ there has been no official encouragement or suggestions of multiple condom use. The high prevalence of multiple condom use found in this population appears to be a community-generated strategy to increase protection from HIV and STDs. The study also showed that CSWs in this population had a very high capacity to negotiate condom use with clients and that many male clients are willing to accept multiple condom use, despite potential decreases in sexual pleasure. Although we could not determine with certainty how this innovation was adopted, several factors undoubtedly were responsible. First, clients may be willing to accede to a CSW's requests to use multiple condoms because of their awareness of the high rate of seropositivity of HIV among brothel-based CSWs in this setting (approximately 60%) and fear of acquiring HIV infection. Second, CSWs may be concerned with acquiring other STDs from male clients and hence sought to protect themselves by using two condoms. Third, CSWs may find it easier to ask a client whether they would prefer to use "one condom or two" rather than asking whether they would use "a condom," thereby increasing the likelihood of condom use.

The purpose of this study was to document the process of how multiple condom use was adopted in this one northern Thai province. To ascertain whether CSW condom use practices in Lamphun Province reflected the behaviors of CSWs in other northern Thai communities, a small observational study of condom use in Chiang Mai brothels was examined after these data were collected. Two brothels in a pilot study provided condoms for one week. Unpublished data showed that multiple condoms were used in 26.5% of 1,231 sex acts. Although the prevalence of multiple condom use in Chiang Mai was not as high as that of Lamphun Province, it is nonetheless impressive. It should be noted that although CSWs in the brothels in the Chiang Mai Province study were generally younger, less educated, and mostly ethnic hill tribe women who therefore might have less empowerment in condom use negotiation, many still used multiple condoms simultaneously for sex with a client.

The data in this study showed that older CSWs, i.e., ≥ 25 years of age, were more likely to use multiple condoms. Older CSWs might have greater negotiating skills in bargaining for multiple condom use than their younger counterparts. In focus group discussions, CSWs were not aware that the use of multiple condoms increased with later clients served in a day (i.e., multiple condoms were used less often with the initial client and increased as the number of clients increased); therefore, the study was unable to explain this phenomenon. Furthermore, CSWs were not able to explain why they tended to use single condoms when having had sex more than once with a client.

The only characteristic of clients consistently associated with multiple condom use (in both quantitative and qualitative data) was older age. This is an encouraging finding because it shows that men whose sexual experience was likely to have begun well before the promotion of condoms have been able to adopt safer sex practices. No association for other client characteristics associated with multiple condom use was found. From focus group discussions, some CSWs tried to use multiple condoms with intoxicated clients, whereas others tried to use single condoms with such men because they believed that intoxicated clients were less likely to maintain erections. Some CSWs would use multiple condoms with clients whom they expected to have long durations of intercourse because of fears of condom breakage, whereas others in similar situations would not use multiple condoms because of fears that this might increase painful intercourse. However, CSWs in this population did report increasing the frequency of multiple condom use to prevent HIV transmission. The important issue in bargaining condom use was to use one or two condoms at a time, not to use none or one condom.

Conclusion

Given the evidence that Thai men in northern Thailand are decreasing their frequency of visiting CSWs³ and that those who are still using commercial sex services have extremely high compliance with the 100% condom use campaign, as well as the high prevalence of multiple condom use found in this study, it is expected that HIV transmission to men through CSW contacts, and to CSWs from HIV-infected clients, may be reduced in this population. Although it has been demonstrated that multiple condom use is associated with significantly less breakage, and CSWs are actively promoting the use of multiple condoms per sex act, we have insufficient information at present to warrant a recommendation for promoting this practice. Additional research will be needed as to the efficacy of this practice and its acceptability among male clients.