Effects of a safe sex intervention on the sexual behavior of brothel sex workers.

We randomly assigned Female Sex Workers (FSWs) employed in our study to one of two treatment groups or the control group. In treatment 1 (T1), SWs participated in a safe sex information session in which they were provided with information on STIs/HIV and safe sex practices. In treatment 2 (T2), they participated in a safe sex information session, and received a counselling session in which they were taught the skills and techniques to negotiate with their clients to get them to wear condoms. For counselling, we adapted four approaches of condom negotiation that were used by Wong et al. (1994), and Maher et al. (2013) with FSWs in Singapore and Cambodia, respectively. The four approaches are the positive approach, fear arousal approach, peer pressure approach and assertive approach. The positive approach highlights the benefits of condom use to clients; the fear arousal approach emphasises the consequences of non-condom use to clients (i.e. increased risk of contracting STIs or HIV/AIDS); the peer pressure approach encourages clients to wear condoms by highlighting that other clients are also wearing condoms; and with the assertive approach FSWs are taught how to encourage clients to use condoms by refusing to have any form of sexual penetration with the client unless he agrees to wear a condom. In addition to the enumerators employed in our study, who were responsible for conducting the baseline survey and T1 intervention, qualified education psychologists were deployed as counsellors to conduct the T2 intervention. The counsellors were trained by a professional counsellor, who had prior counselling experience in HIV/AIDS prevention programmes in Bangladesh, on how to conduct the condom negotiation session with the participants. Both interventions were conducted between April 2016 and June 2016. The follow-up survey was conducted with all participants between October 2016 and November 2016, which was approximately eight months after the baseline survey was first rolled out, and approximately six months after the intervention first commenced. 2.3.1 T1: Safe sex information intervention The safe sex information intervention was carried out between each enumerator and participant, one at a time, in the participant’s room. Each enumerator began the intervention by providing participants with information on STIs with the help of a flipchart. The STIs that we focused on were chlamydia, gonorrhoea, syphilis, hepatitis B and HIV/AIDS. The flipchart provides information on the symptoms, consequences, testing, treatment, and prevention of these STIs. The flipchart also provided pictorial examples of the STIs. Once the flipchart was completed, the enumerators proceeded to show participants a seven-minute video on HIV/AIDS, which was specifically prepared for this purpose. The HIV/AIDS video was prepared with assistance from experts in the sex work industry with the objective of educating participants on safe sex behaviour. To ensure that the video was relevant to the participants, we employed actresses to play the role of sex workers working in brothels. We then instructed the enumerators to conduct a health knowledge test with the participants to ensure that the participants understood and remembered the safe sex information provided to them. The health knowledge test is made up of twenty items and was conducted after the enumerators had completed the flipchart session and participants had watched the video. The enumerators began the test by reading out the first question followed by the available options that the participants could choose as their answers. After the participant answered the first question, the enumerators then proceeded to the second question. This process continued until participants had answered all twenty questions. At the end of the test, the enumerators tallied the total score. If the participants failed to get full marks on their first attempt at the test, the enumerators went over the incorrectly answered questions and provided participants with the correct answers to these questions. Once this process was completed, the enumerators conducted the test with the participants again. The maximum number of attempts allowed for the test was two. At the end of the test, participants in T1 were paid 100 Taka (US$1.28) each to compensate them for their time. The whole process for the T1 intervention took between thirty to forty minutes to complete. 2.3.2 T2: Safe sex information plus counselling intervention Similar to T1, the safe sex information session and counselling session were carried out between one counsellor and one participant at a time in the participant’s room. The safe sex information session in T2 followed the same process in T1 as discussed above. Once the safe sex information session was completed, the counsellors proceeded with the counselling session in the participant’s room. The counselling session was done in a relatively informal manner. Instead of immediately addressing the four approaches available for condom use negotiation, the counsellors began by asking participants general questions about their occupation and work experience. The purpose of doing this was to create a more comfortable discussion environment, and build trust, so that participants were more willing to share their commercial sexual experiences with the counsellors. This has also helped the counsellors to tailor the way that they presented the four approaches to condom use negotiation based on the responses of participants. At the end of the counselling session, participants in T2 were paid 150 Taka (US$1.92) each to compensate them for their time. T2 took between sixty to seventy-five minutes to complete. A follow-up session was also conducted between the counsellors and their assigned participants one week after the T2 intervention for both the T1 and T2 participants. The follow-up session was conducted between one counsellor and one participant at a time in the participant’s room. Each follow-up session was conducted over approximate 30 minutes. The purpose of the follow-up session was to gain a brief understanding of the safe sex behaviour of the participants with their clients after the intervention, and for the counsellors to remind the participants about the four approaches to condom use negotiation. No data was collected during this follow-up session. Monitoring to check the adherence or compliance of the interventions was not conducted because of the pattern of the study population.