山东省女性性工作者艾滋病高危行为变化及抽样方法研究
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摘要
研究背景
艾滋病已成为全球许多国家重大的公共卫生和社会问题,艾滋病在世界范围内继续蔓延,己成为危害人类生命和健康最严重的传染性疾病之一,对社会文化、经济和政治均有重大影响。虽然目前中国艾滋病疫情处于总体低流行,但中国地域广阔,人口众多,经济发展不平衡,特定人群和部分重点地区已经出现艾滋病高流行态势,疫情正在从高危人群向一般人群扩散,性传播已经成为中国艾滋病传播的主要传播途径,在2009年新增艾滋病感染案例中占到70%以上。山东省艾滋病新报告感染者经性途径传播也呈上升趋势,2009年经性途径传播所占比例达到70.9%。性传播途径所占比例的增加有着重要的涵义,根据非洲国家的经验,当性传播成为艾滋病传播主要途径,那么它的流行速度是惊人的。因此,控制艾滋病经性传播具有重要意义。
性传播成为主要的传播方式与商业性交易的广泛存在密不可分,女性性工作者(female sex workers,FSWs)作为特殊的桥梁人群,在性病艾滋病的传播过程中起着重要的作用,了解这一高危人群的艾滋病感染状况及相关行为状况对控制艾滋病疫情有重要意义。山东省自1995年开始,对女性性工作者进行艾滋病血清学监测,经过多年的实施,为山东省女性性工作者艾滋病感染状况提供了很多的信息。同时,也暴露了血清学监测的缺点,即不能反映影响艾滋病性病传播流行的社会、行为因素,艾滋病感染的流行特征和流行因素尚不明了,具有滞后性。同时山东省艾滋病流行的各种因素广泛存在,如性病发病率的增加、流动人口的剧增、人们对性观念、性行为认识的改变,导致卖淫、嫖娼现象的增加。此外,世界卫生组织的报告认为,根据近年来毒品的流行趋势,苯丙胺类新型毒品将在一定程度上替代海洛因在亚洲及其他国家蔓延流行,但是目前,只看见西方国家在男男性行为人群中新型毒品滥用研究结果相关报到,而对于女性性工作者这一桥梁人群的新型毒品滥用情况一无所知。因此,极需在山东省开展女性性工作者这一特殊桥梁人群行为学调查。因此,我们选择在青岛、烟台和德州3个地市,连续3年在同一时间段采用同一种调查方法对女性性工作者进行调查,以期了解该桥梁人群的性病艾滋病感染状况及其相关行为特征,探索流行因素和流行趋势,对山东省今后制订艾滋病防治策略、开展行为干预提供科学依据。
同时,女性性工作者作为一个敏感的群体,由于担心受到社会排斥和公众歧视,她们不愿公开表露自己的身份,行为一般比较隐蔽,常隐匿性活动,称之为隐蔽人群。在针对隐蔽人群的调查研究中,由于缺乏对这些人群的抽样框架,对于这些难以接近人群的抽样是研究者面临的一项持续性挑战。因此,探索有效抽样方法对该人群的艾滋病防制意义重大。
同伴推动抽样(respondent-driven sampling,RDS)是近年来发展起来的一种近似概率抽样的链式推举抽样,该方法还可通过统计学调整来消除由于人们通过社会网络进行征募而出现的内在固有的偏移,为开展该人群调查并进行有代表性的估计提供了理论基础和有效途径,是一种较适合的接近隐蔽人群的抽样方法。目前,国内外已有大量关于RDS方法应用于男男性行为人群及吸毒人群的研究报告,而应用该方法调查女性性工作者的报告很少。本课题拟应用这一新技术新方法在济南市历城区开展女性性工作者调查,以期了解这一新技术新方法在该人群中的可应用性,评价其效果,同时了解当地女性性工作者的艾滋病及梅毒感染率、人口构成、高危行为情况以及与她们相联系的社会网络的信息,为当地制定艾滋病防治策略、开展行为干预提供科学依据。
研究目的
1.女性性工作者性病艾滋病感染状况及其流行因素；
2.女性性工作者性病艾滋病传播相关的行为特征及其影响因素；
3.女性性工作者性病艾滋病感染及行为变化趋势,为艾滋病疫情的估计和预测提供信息；
4.评估我省已开展的干预活动,为当地制定艾滋病防治策略、开展行为干预提供科学依据；
5.探索同伴推动抽样方法在招募女性性工作者中的应用并对其进行评价,为以后对该人群的抽样研究提供借鉴和参考。
研究方法
1.采用流行病学现场调查方法,选择青岛、烟台和德州三个调查点,连续3年在同一时间段采用分层整群抽样方法对女性性工作者进行横断面问卷调查,了解这一人群社会人口学特征、艾滋病相关知识知晓情况、性行为及其安全套使用情况、吸毒行为、求医行为、接受干预服务等信息,并采集血液进行HIV、梅毒抗体检测；使用Epidata3.0建立数据库,采用SPSS11.0统计软件进行数据的频数、均数、方差分析、卡方检验、分层分析、单因素和多因素Logistic回归分析等统计分析。
2.采用同伴推动抽样方法招募女性性工作者,调查点设置在济南市历城区疾控中心,招募过程由最初的7个“种子”开始,发给每个种子3张联系卡,由种子介绍其同伴加入研究群体,被介绍的人得到3张联系卡,又继续介绍别人,按这样的方式,推举链不断延长,样本像滚雪球一样逐渐增大,直到达到预期样本量,招募过程中采用了双重激励措施。运用RDSAT、NetDraw和SPSS 11.5分析软件进行资料的整理分析。
研究结果
1.山东省女性性工作者艾滋病高危行为变化及流行因素研究
三年共调查女性性工作者3460例,检出HIV抗体阳性者2例,HIV抗体阳性检出率为0.06%；调查对象年龄范围在15-53岁之间,年龄分布以20-24岁年龄段为主,占54.6%,婚姻状况以未婚为主,占75.9%,户籍地以本省为主,占52.0%,本省户籍的女性性工作者逐年增加,差异有显著性(P(0.001),女性性工作者文化程度有增高趋势,2006年高中及以上学历占14.7%,而2008年则占22.5%,差异显著(P<0.001)。
调查对象发生初次性行为年龄范围为11-29岁,首次商业性行为年龄范围在12-45岁之间,有47.5%的调查对象在20之前开始从事性服务工作,46.0%的调查对象从事商业性行为工作不到2年,57.8%的调查对象近一周接客数量多于7个。72.3%的FSWs最近一次与客人发生性行为时使用了安全套,2008年较2006年有了显著提高,差异有显著性(P<0.001)；最近一个月与客人发生商业性行为坚持使用安全套率不高,2006-2008年坚持使用安全套率分别为32.6%、53.6%和48.2%,差异有显著性(P<0.001)；最近一次与固定性伴发生性关系时3年平均有45.3%的FSWs使用了安全套,安全套使用率从2006年31.1%提高到2008年57.5%,使用率显著提高(P<0.001),最近一个月内与固定性伴发生性行为,三年坚持安全套使用率均很低,2006-2008年坚持使用安全套率分别为18.0%、17.6%和40.5%,差异有显著性(P<0.001)。
有45.6%的FSWs承认在最近一年出现过性病相关症状,但三年患病率未见明显改变(P>0.05),其中有72.6%的人会选择到正规医院诊疗,这一比例从2006年的38.1%上升到2008年的92.1%,差异有显著性(P<0.001),有部分女性性工作者(40.6%)在出现性病相关症状时会选择自己买药治疗,但这一比例有所下降,从2006年的54.7%下降到2008年的32.5%,差异有显著性(P<0.001)。
女性性工作者艾滋病知识知晓率有增加趋势,2006-2008年分别有75.3%、83.8%和84.6%的调查对象艾滋病知识得分≥6,女性性工作者获取艾滋病相关知识主要来源为免费宣传材料,3年平均为80.1%,其次为电视,占71.8%,2006-2008年女性性工作者获得艾滋病知识渠道变化很大,通过朋友、医生、咨询服务、宣传广告栏以及免费宣传材料几种方式获取知识比例在逐渐增加,而电视和广播所占比例在逐渐下降；最近一年接受艾滋病病毒检测比例不高,但有逐年增加趋势,2006-2008年分别为16.2%、29.8%和47.6%,差异有显著性(P<0.001)；FSWs接受过安全套发放等干预服务有逐年增加趋势,各项服务接受率均显著性提高(P<0.001)。
分层结果显示,不同场所、年龄、婚姻状况、文化程度、民族、艾滋病知识得分以及是否接受过干预服务之间安全套使用率有显著性差异。FSWs最近一个月商业性行为不坚持安全套使用与年龄两极化(<20和≥25年龄组)、较低文化水平、招募场所为路边店/站桩、出现过性病相关症状以及没有接受过安全套发放服务相关；最近一个月与固定性伴发生性行为不坚持安全套使用与≥25年龄、未婚、少数民族、出现过性病相关症状以及未接受性病检查或治疗相关。
3年共有11.2%的调查对象承认有吸毒史,其中有2.8%的对象承认在过去半年内注射过毒品。青岛、烟台和德州三个调查点的FSWs承认有吸毒行为比例分别为30.2%、2.0%和0.0%,青岛吸毒FSWs全部承认吸食的毒品为“冰毒”,有部分(4.5%)FSWs同时也吸食过“麻谷”和“K粉”。85.7%(36/42)的梅毒阳性来自于青岛监测点,因此单独分析青岛资料以了解FSWs吸毒行为及梅毒感染的相关影响因素。
青岛调查点三年共调查女性性工作者1211名,年龄分布以20-24岁年龄段为主,占41.9%,婚姻状况以未婚为主,占85.1%,户籍地以本省为主,占65.8%,文化程度以初中文化为主,占83.8%。58.1%的调查对象在20岁前开始从事性服务工作,60.2%的调查对象从事商业性行为工作不到2年。63.5%的调查对象最近一周按客数大于或等于7个。最近一个月与客人发生商业性行为坚持使用安全套率不高,仅为42.0%,最近一个月与固定性伴发生性行为时坚持使用安全套率仅为7.3%。被调查女性性工作者中,有30.2%的调查对象承认有吸毒史,其中有1.6%的对象承认在过去半年内注射过毒品,低年龄组、未婚、招募场所为桑拿/夜总会／酒吧、首次性交年龄<18岁、从事商业性行为年限≥2、最近一个月商性性行为未能坚持使用安全套以及更高的梅毒感染率是FSWs吸毒行为的危险因素。三年共有3%的被调查对象检测为梅毒抗体阳性,这一比例从2006年的1%增加到2008年6.9%,差异具有显著性(P<0.001)。梅毒感染与最近一个月商业性行为未坚持使用安全套、有吸毒史以及曾经做过HIV检测有关。
单独分析青岛FSWs调查资料了解工作场所对女性性工作者行为影响,结果显示：招募场所为站桩/路边店的女性性工作者年龄较大、文化程度更低一些,而夜总会/酒吧的女性性工作者以未婚、文化程度较高以及本省户籍为主。不同场所的女性性工作者首次商业性行为年龄、最近一周客人数量以及吸毒行为有显著差别,61.1%的夜总会/酒吧/桑拿的女性性工作者首次商业性年龄小于20岁,而这一比例在站桩/路边店以及洗脚屋/发廊女性性工作者中为49.2%和50.4%。站桩/路边店以及洗脚屋/发廊的女性性工作者最近一周客人数量较多,最近一周客人数量≥7的比例分别为95.0%和91.4%,而仅有50.4%的夜总会/酒吧/桑拿女性性工作者最近一周客人数量≥7；33.0%的夜总会/酒吧/桑拿女性性工作者有吸毒行为,而这一比例在站桩/路边店以及洗脚屋/发廊女性性工作者中仅为15.8%和28.3%。站桩/路边店以及洗脚屋/发廊的女性性工作者求医行为更不规范,2/3的女性性工作者会选择自己买药治疗或不去治疗；站桩/路边店的女性性工作者接受艾滋病相关干预服务的可及性较夜总会等高档场所低,接受免费安全套发放、同伴教育及艾滋病相关宣传材料均较夜总会/酒吧/桑拿及洗脚屋/发廊的女性性工作者的比例低,有显著性差异。多因素分析结果显示,未婚、外省户籍、初次性行为年龄(18岁是站桩/路边店的女性性工作者吸毒行为的危险因素；(25岁年龄组、初次性行为年龄<18岁、从事商业性行为年限≥2年、与商业性伴最近一个月不安全性行为以及更高的梅毒感染率是夜总会/酒吧/桑拿的女性性工作者吸毒行为危险因素；外省户籍、<20岁年龄组以及与商业性伴最近一个月不安全性行为是洗脚屋/发廊的女性性工作者吸毒行为的危险因素。夜总会/酒吧/桑拿女性性工作者梅毒感染与具有吸毒行为及曾做过HIV检测有关；而洗脚屋/发廊女性性工作者梅毒感染与从事商业性行为年限长有关。多因素分析结果显示,站桩/路边店女性性工作最近一个月与商业性伴不安全性行为与未婚和从未做过HIV检测有关；夜总会/酒吧/桑拿女性性工作者最近一个月与商业性伴不安全性行为与具有吸毒行为、从未做过HIV检测、文化程度低以及出现性病相关症状时不去治疗有关；洗脚屋/发廊女性性工作者最近一个月与商业性伴不安全性行为与具有吸毒行为以及出现性病相关症状时不去治疗有关。
2.同伴推动抽样方法在女性性工作者中的应用研究
共调查了363个女性性工作者,最长的招募链为25波。FSWs的年龄、文化程度、户籍、收入状况以及最近一个月商业性行为安全套使用等评价指标均达到了平衡。调查对象年龄最小为17岁,最大为48岁,中位数为27岁,以未婚、≥25岁年龄组、初中文化程度、外省户籍女性性工作者居多。
FSWs艾滋病性病知晓率较低,59.2%的FSWs认为“蚊虫叮咬会传播艾滋病”,41.8%不认为及时治疗性病有助于预防艾滋病,高达50.4%的FSWs存在性行为后冲洗阴道或用一些外用药可以预防艾滋病的错误认识。高达58.8%的FSWs认为自己不会感染或者不知道是否会感染艾滋病,只有12.5%的FSWs认为自己有高度感染艾滋病的危险性,仍在三分之一以上的FSWs不知道女性和男性得了性病后会有哪些症状。49.0%的FSWs为了预防性病,会定期打消炎针或吃消炎药。
首次性行为的年龄为10-28岁,首次商业性性行为的年龄为16-45岁,42.4%的FSWs从事商业性行为年限≥2年,调查对象中31.1%有一夜情或临时性伴,75.2%有固定性伴。在安全套使用方面,最近一次与商业性伴、非商业临时性伴及固定性伴发生性行为时的安全套使用率分别为88.5%、46.3%和43.6%,最近一个月与商业性伴、非商业临时性伴及固定性伴发生性行为坚持安全套使用率分别为60.8%、58.8%和22.4%。
75.8%的FSWs有饮酒史,53.4%的FSWs有吸烟史,12.7%有吸毒史,其中8.7%有注射吸毒史,均为海洛因滥用者,另外91.3%的FSWs均为吸食冰毒、K粉及摇头丸新型毒品者。只有44.9%的FSWs在最近一年接受过安全套发放、性病检查治疗、艾滋病咨询等服务,18.7%曾做过艾滋病检测。血清学检测未检出HIV抗体阳性者,梅毒感染率为5.4%。多因素Logistic回归模型结果显示,<20岁和≥25年龄组、本省户籍、低档场所以及具有吸毒行为是历城区FSWs最近一个月无保护商业性行为的危险因素。未婚、本省户籍、初次性行为年龄(18岁以及最近一个月商业性行为未坚持安全套使用是吸毒的危险因素。
结论
1.山东省女性性工作者艾滋病高危行为变化及流行因素研究
1.1女性性工作者作为艾滋病病毒传播的高危人群,其感染状况及行为状况直接反映山东省艾滋病的流行强度,通过对这一高危人群开展血清学和行为学调查结果显示,山东省女性性工作者艾滋病感染率目前总体仍处于较低水平；
1.2 2006-2008年女性性工作者艾滋病知晓率、安全套使用率以及干预服务接受率均显著增加,提示艾滋病防治工作产生一定成效。但是安全套使用率低、多性伴、吸毒行为以及性病感染比例增加等因素广泛存在,说明山东省FSWs仍面临性病艾滋病感染巨大风险；
1.3 FSWs最近一个月商业性行为不坚持安全套使用与年龄两极化(<20和≥25年龄组)、较低文化水平、招募场所为路边店/站桩、出现过性病相关症状以及没有接受过安全套发放服务相关；最近一个月与固定性伴发生性行为不坚持安全套使用与≥25年龄、未婚、少数民族、出现过性病相关症状以及未接受性病检查或治疗相关；
1.4高达30.2%的青岛市女性性工作者存在新型毒品滥用行为,单因素和多因素分析均显示吸食新型毒品与不安全性行为及梅毒感染有关,进一步说明了吸食新型毒品将是影响性病艾滋病在该类高危人群中传播的一个重要危险因素；
1.5低年龄组、未婚、招募场所为桑拿/夜总会/酒吧、首次性交年龄<18岁、商业性行为年限≥2、与商业性伴最近一个月未坚持安全套使用以及更高的梅毒感染是FSWs吸毒危险因素。FSWs梅毒感染主要与最近一个月商业性行为未坚持使用安全套、吸毒史以及曾经做过HIV检测有关；
1.6新型毒品滥用这一影响因素导致夜总会等高档场所FSWs不安全性行为及性病感染率较低档场所还要高的现象,与传统干预策略不一致,因此应加强对夜总会/酒吧/桑拿场所中具有吸毒行为的FSWs干预工作,但同时也不能忽视站桩/路边店FSWs吸毒比例也在增加,从2006年的5.0%增加到2008年的25.8%；
1.7FSWs存在多种易感染艾滋病的不安全行为,性病感染率高,就医方式还很不规范,需要实施综合干预,加大对这一人群的健康教育、行为干预及安全套推广等工作,并且针对不同人口学特征的FSWs有不同的艾滋病高危行为这一特点,制定不同的干预措施。
2.同伴推动抽样方法在女性性工作者中的应用研究
2.1运用RDS招募FSWs是可行的,有其独特的优点,同时也存在一些不足,仍需不断完善和发展。
2.2历城区FSWs艾滋病性病感染率较低,但不安全性行为广泛存在,FSWs是HIV传播的“桥梁人群”,可利用其社会网络特征来加强对这一高危人群的干预工作。
2.3 FSWs性病艾滋病知晓率较低,历城区仍需要更加灵活运用有效的健康宣传和外展服务,重视同伴教育,宣传正规途径治疗,同时加强风险意识教育。
2.4<20岁和≥25年龄组、本省户籍、低档场所以及具有吸毒行为是历城区FSWs最近一个月无保护商业性行为的危险因素。未婚、本省户籍、初次性行为年龄<18岁以及最近一个月商业性行为未坚持安全套使用是吸毒的危险因素。
2.5新型毒品滥用情况不容乐观,应采取有针对性的对策和措施,有效防范和遏制“新型毒品”的蔓延。
意义和创新
1.本研究采用生物学监测与行为学监测相结合,连续3年在同一时间段、同一调查地点采用同一种调查方法对FSWs进行调查,样本量大,代表性强,能够很好的反映山东省FSWs的危险行为特点及其变化趋势；
2.在国内首次报到FSWs新型毒品滥用现象及其影响因素,青岛FSWs新型毒品滥用比例高达30.2%,单因素及多因素分析均显示新型毒品滥用与梅毒感染、不安全性行相互关联性,进一步说明了新型毒品滥用将是影响我省性病艾滋病传播的一个重要危险因素,具有重要的公共卫生学意义；
3.传统的干预思路认为应加强路边店等低档场所FSWs的干预工作,忽略了新型毒品滥用这一影响因素而导致的夜总会等高档场所不安全性行为及性病感染率高的现象,本研究对今后制定我省艾滋病防治干预策略有重要指导意义；
4.本研究首次在山东省应用同伴推动抽样这一新技术新方法探索在女性性工作者中的应用,为以后对该人群以及其它隐蔽人群的抽样研究提供借鉴和参考。
Background
The human immunodeficiency virus (HIV/AIDS) epidemic has become a major global public health and social problems in many countries. AIDS has become one of the most serious infectious diseases to human life and health, and increasingly contributes to the erosion of civil order and economic growth. Although the AIDS epidemic in China is still in the overall low prevalence, there are significant geographic variations in HIV prevalence in difference Province, some specific groups have emerged high HIV prevalence. The epidemic is spreading from high-risk groups to the general population. Sexual contact has become the dominant modes of HIV transmission, more than 70% were infected through sexual contact in the newly reported HIV/AIDS cases in 2009. The proportion of sexual contact has also been increasing in the newly reported HIV/AIDS cases in Shandong Province,70.9% were infected through sexual contact in the newly reported HIV/AIDS cases in 2009. The increasing proportion of sexual transmission has important implications. According to the experience of African countries, when the sexual transmission became the main mode of HIV transmission, then the epidemic will rise rapidly. Therefore, the control of AIDS through sexual transmission is important.
Sexual transmission becoming a major mode of transmission was associated with the widespread presence of commercial sex trade, female sex workers (FSWs), as a special bridge groups, plays an important role in the transmission process. Hence, to understand their status of HIV infection and related behaviors will have importance meanings to control the HIV/AIDS epidemic. Since 1995, HIV serological surveillance among female sex workers was started to implement in Shandong Province, which had provide lots of information about the status of HIV prevalence among FSWs, while, it has also exposed the shortcomings of the serological surveillance, which does not reflect the social and behavioral factors of AIDS epidemic, those risk factors associated with HIV/STD infection and high risk behaviors are not clear. At the same time, there are many potential risks to spread the epidemic in Shandong province, such as increasing STD prevalence, increasing mobility population, broader sexual freedom with more tolerant views, concurrent with the increasing of commercial sex in Shandong Province. In addition, the World Health Organization (WHO) reported that methamphetamine use will become a major public health issue in the world, and will spread to replace heroin in some extent in Asia and other countries. But for now, Methamphetamine use and related risk factors has been only reported among MSM in western countries, and few studies have investigated methamphetamine use among FSWs. Thus, behavioral investigation among FSWs should be conducted in Shandong province to understand their status of HIV/STD prevalence and risk factors. Therefore, three consecutive cross-sectional surveys with consistent recruiting procedures were conducted among FSWs across 3 cities from 2006 to 2008, in order to explore their status of HIV/STD infection and behavioral characteristics, to understand HIV-related behavior change trends and assess their potential roles in the HIV epidemic, which will be helpful for HIV/AIDS control in the future.
Female sex workers is also called hidden populations, are a sensitive group, they don't want to reveal their identity in public for the reason of discrimination. It is a continuing challenge for researchers to get a representative sample among those hidden populations. Therefore, exploring the effective sampling method will be special meaning for AIDS control.
Respondent driven sampling is a new form of chain referral sampling method to sample a hidden population, it also claims to produce an unbiased indicator for population estimates through special statistical soft to analyze the variability of indicators and thereby compute standard errors for population estimates. RDS has been applied in many research programs to sample hard-to-reach and hidden populations such as IDUs and MSM, however, the RDS method has not been widely applied for recruiting FSWs. This study was conducted to recruit FSWs using RDS method to explore and evaluate application of respondent driven sampling in the recruitment of female sex workers, and to investigate demographic characteristics, their status of HIV/STD infection, their social network information, and high risk behaviors of female sex workers, and offer scientific evidence for developing intervention strategy.
Objects
1. To understand HIV/STD prevalence and risk factors among female sex workers.
2. To understand HIV-related behavioral characteristics and risk factors among female sex workers.
3. To understand HIV/STD prevalence and behavioral change trends among female sex workers, and provide information for the HIV/AIDS epidemic estimation.
4. To evaluate intervention effect, and provide scientific basis for making intervention strategy.
5. To explore and evaluate application of respondent driven sampling in the recruitment of female sex workers, and provide reference for future research in this population.
Methods
1. Three consecutive cross-sectional surveys with consistent recruiting procedures were conducted among FSWs across 3 cities in 2006,2007 and 2008, respectively. Questionnaire-based interviews provided demographic and social information, sexual behaviors and condom use, drug use behavioral information, HIV knowledge and perceptions, ever had STD-related symptoms, and ever received HIV-related services. Blood samples were collected from all participants to test their status of HIV and syphilis prevalence. Survey data were recorded with EpiData software. SPSS11.0 software was applied for all statistical analyses, such as mean, variance analysis, chi-square test, stratified analysis, univariate and multivariate Logistic regression analysis.
2. Respondent driven sampling was used to recruit female sex workers, seven seeds were recruited through the local key informants to participate in the study. After the seeds completed the interview, each of them was given three coupons for recruiting their peers into the study. Three coupons for referring peers were given to the participants when they finished the interview and the sample collection. The desired sample size will be gotten by this chain-referral sampling method. All new recruits were offered a dual incentive, one for completing the interview and on for recruiting. RDSAT, NetDraw and SPSS 11.5 software were applied for data analysis.
Results
1. The results of high risk behavioral change research among FSWs in Shandong Province
3,460 participants in total were investigated in the three years, of the participants, 2 were HIV-infected (1 in 2006 and 1 in 2008).54.6% were 20-24 years of age,75.9% were unmarried, and 52.0% coming from local province. The proportion of FSWs coming from local province was increasing, there was a significant difference (P<0.001), and education level of FSWs was increasing with 14.7% received high school or high education in 2006 and 22.5% in 2008.
The age of first sex experience was from 11 to 29 years old, and the age of first commercial sex was from 12 to 45 years old.47.5% started sex work<20 years of age, 46.0% had<2 years of sex work experience, and 57.8% had≥7 paying clients in the past week.72.3% reported condom use with client in the last sex behavior, there was a significant difference compared 2008 to 2006 (P<0.001). The rates of consistent condom use for FSWs with clients in the last month were 32.6%,53.6%, and 48.2%, respectively. there was a significant difference(P<0.001).45.3% reported condom use with regular partners in the last sex behavior, there was a significant increase compared 31.1% in 2006 to 57.5% in 2008(P<0.001). The rates of consistent condom use for FSWs with regular partners in the last month were 18%,17.6%, and 40.5% in 2006,2007, and 2008, respectively, there was a significant difference (P<0.001).
45.6% of the FSWs reported ever appear STD-related symptoms, but there wasn't a significant difference in the three years (P>0.05), of which 72.6% will choose hospital to treatment, the proportion was increasing from 38.1% in 2006 to 92.1% in 2008, there was a significant difference (P<0.001). Some of FSWs may choose to treat by buy medicine from shopping, but the proportion decreased, from 54.7% in 2006 to 32.5% in 2008, the difference was significant (P<0.001).
The HIV/AIDS knowledge scores≥6 among FSWs were 75.3% in 2006, 83.8% in 2007, and 84.6% in 2008, the major mode for FSWs to access HIV-related knowledge was free promotional materials, accounting for 80.1%, followed by television, accounting for 71.8%. The proportion of FSWs access HIV-related knowledge channels was vary widely, the proportion of by friends, doctors, consulting services, advertising columns, and free publicity material were gradually increase, while the proportion of by television and radio gradually decline. The proportion of ever received HIV test was not high, but there was a rising trend with 16.2% in 2006, 29.8% in 2007,and 47.6%in 2008, the difference was significant (P<0.001).The proportion of ever received intervention service was increasing, there is a significant difference in each intervention item(P<0.001)
Stratified analysis results showed that Different places, age, marital status, education level, ethnicity, AIDS knowledge score and whether ever received intervention services were have difference condom use rate. Unconsistent condom use with clients in the last month was independently associated with being<20 or≥25 years of age, lower education, being recruited from Non-venue based establishments, self-reported STD-related symptoms, and never received free condom. Unconsistent condom use with regular sex partners in the last month was independently associated with being≥25 years of age, being single, minority ethnicity, self-reported STD-related symptoms and never received STD examination and/or treatment.
Of the participants,11.2% reported ever using illicit drugs with 2.8% ever injecting drugs. The proportion of ever using drug was 30.2% in Qingdao,2.0% in Yantai, and 0.0% in Dezhou, respectively. All drug using FSWs in Qingdao admitted taking methamphetamine, and some (4.5%) FSWs also smoked "Magu" and "K powder". Most of FSWs (85.7%) who had infected syphilis were coming from Qingdao survey site, so the data from Qingdao was analyzed separately, in order to understand the risk factors of drug using and syphilis infection.
1211 eligible participants were investigated in Qingdao city in the three years, 41.9% were 20-24 years of age,85.1% were single,65.8% were Shandong residents, and 83.8% received middle school of education. Of 1211participants, nearly half had first lifetime sex at <18 years of age; 58.1% started sex work at <20 years of age; 60.2% only had <2 years of sex work experience, two-thirds had≥7 clients in the past week. Only 7.3% reported consistent condom use with regular sex partners and 42% with clients in the last month.30.2% reported using methamphetamine in the last 6 months with 1.6%(6) of the methamphetamine users ever injecting. Analysis results showed, methamphetamine users were more likely to be younger, single, recruited from Sauna/bath/KTV,<18 years of age at first lifetime sex,≥2 years of duration of commercial sex, have inconsistent condom use with clients in last month, and be syphilis-infected. Of 1211 participants,3% were syphilis-infected, with a dramatic increase from 1% in 2006 to 6.9% in 2008. The syphilis-infected participants were more likely to be ever having used methamphetamine, have inconsistent condom use with clients in last month, and have been tested for HIV.
Female sex workers are at greater risk of experiencing harm from their club drug use, since clients often solicit FSWs in different venues to share drug and sex experiment. Hence, separate analyze was taken for the Qingdao data, in order to assess the impact of commercial sex venues on the syphilis and methamphetamine epidemics among FSWs. The results showed that The FSWs recruited from street-based entertainment were more likely to be older age and lower education level, while, FSWs recruited from night clubs or bars were more likely to be unmarried, higher education level and local residence. There were significant difference on the age of first commercial sex, the number of clients in the past week and drug behaviors, At the venue of saunas, night clubs or bars,61.1% started sex worker at <20 years of age, and the proportion were 49.2% at the venue of street-based entertainment and 50.4% at the venue of hair/beauty salons. Those FSWs recruited from street-based entertainment and hair/beauty salons had higher number of clients in the past week, the proportion of number of clients in the past week≥7 were 95.0% and 91.4%, respectively, while only 50.4% at the venue of saunas, night clubs or bars.33.0% FSWs recruited from saunas, night clubs or bars reported using methamphetamine, the proportion were 15.8% in street-based entertainment and 28.3% in. More than two third of FSWs recruited from street-based entertainment and hair/beauty salons may buy medicine from a pharmacy or don't cure if they felt uncomfortable. The FSWs recruited from street-based entertainment had lower proportion to receive intervention service than night clubs, had a lower proportion of ever received free condom, peer education and HIV-related materials, there was a significant difference.
In the multivariate analysis, the street-based methamphetamine users were more likely to be single, not recruited from Shandong Province and have first lifetime sex <18 years of age. The night clubs/bars/sauna-based methamphetamine users were more likely to have their first lifetime sex<18 years of old, have had sex work≥2 years, younger age, had unprotected sex with clients in the last month and syphilis-infected. The hotels/hair/beauty salons-based methamphetamine users were more likely to be recruited from non-Shandong other provinces,<20 years of age and had unprotected sex with clients in the last month.
In multivariate analysis, the night clubs/bars/sauna-based FSWs with syphilis infection were more likely to be methamphetamine users and have already attended HIV testing; the hotels/hair/beauty salons-based FSWs with syphilis infection were more likely to have had sex work≥2 years and syphilis infection.
In multivariate analysis, the street-based FSWs who reported had unprotected commercial sex were more likely to have not received HIV testing and being single; The night clubs/bars/sauna-based FSWs who reported had unprotected commercial sex were more likely to have not received HIV testing, less education, had unprotected sex with clients in the last sex, be methamphetamine users and not sought any treatment for their STD symptoms; the hotels/hair/beauty salons-based FSWs who reported had unprotected commercial sex were more likely to be methamphetamine users and not sought any treatment for their STD symptoms.
2. The results of application of respondent driven sampling in the study among female sex workers
In total 363 participants, were recruited for the study. The longest recruitment tree had 25 recruitment waves, the evaluation variables including age, educational level, residence, income, and condom use with commercial sex partners in the last month have reached equilibrium. Of the total 363 participants, the youngest participant was 17 years and the oldest was 48 years old, the median age was 27 years. Most of the participants were unmarried,≥25-year-old age group, junior middle school education and coming from other provinces.
The estimated population proportion has a low awareness of AIDS,59.2% of participants think mosquito bites can spread AIDS,41.8% do not think that timely treatment can help prevent AIDS, a high proportion of 50.4% think that washing the vagina after having sex or using some external use the mistake can prevent AIDS. Up to 58.8% of the participants think they will not or do not know whether infect AIDS infect, only 12.5% perceived themselves will have a high risk of HIV infection. More than one third of the FSWs do not know the symptoms of STDs among females and males.49.0% regularly use anti-inflammatory medicine in order to prevent sexually transmitted diseases.
The age for the first sex experience ranged from 10 to 28 years old, the age for initiating commercial sex ranged from 16 to 45 years old.42.4% of participants have the duration of being a sex worker≥2 years.
The proportions who had non-regular non-paying partners and regular partners was 31.1% and 75.2%. The condom use rate in the last sex with clients, non-regular not-paying partners and regular partner were 88.5%,46.3% and 43.6%, and the condom use rate in the last month were 60.8%,58.8% and 22.4% respectively.
The estimated population proportions who had drinking history was 75.8% and 53.4% had smoking history.12.7% had history of ever using drug, among which only 8.7% had history of injection heroin drug use, while 91.3% of FSWs were taking new type drug including methamphetamine, K powder and ecstasy. Only 44.9% of FSWs had ever received condom distribution, STD examination and treatment, or AIDS counseling and other services in the last year, and 18.7% had ever taking HIV testing. None of the participants were HIV-positive, and the syphilis prevalence was 5.4%.Multivariate Logistic regression model showed that< 20 and≥25 years old groups, Shandong province residence, low establishment-based places and ever drug use were risk factors associated with unprotect commercial sex behaviors in the last month. Unmarried, Shandong province residence,<18 years old of the age for the first sex experience, and not continuous condom use with clients in the last month were risk factors associated with drug abuse.
Conclusions
1. High risk behavioral change research among FSWs in Shandong Province
1.1 Female sex workers were the high risk population in the HIV/AIDS epidemic, their status of HIV infection and behaviors can reflect the epidemic in Shandong province. The results of this study showed that the HIV prevalence of FSws was still at a relatively low level in Shandong province.
1.2 This study showed an increasing proportion on the AIDS awareness, condom use, and intervention services coverage from 2006 to 2008, which indicated the effectiveness of AIDS prevention and control in some extent. Nevertheless, there are many potential risks to spread the HIV epidemic in Shandong province, such as low condom use, multiple sex partners, drug use, and increasing STD prevalence.
1.3 The FSWs who reported had unprotected commercial sex in the last month were associated with <20 and≥25 age groups, lower education level, recruited from street-based establishment, ever having STD-related symptoms and never received free condoms. Inconsistent condom use with regular partners in the last month was independently associated with≥25 years age, single, minority, ever having STD-related symptoms and never received STD examination and treatment.
1.4 Up to 30.2% of female sex workers in Qingdao were methamphetamine users, univariate and multivariate analysis results showed that methamphetamine use was associated with unprotected sex behaviors and syphilis infection, which further illustrates "new type" drugs will be an important risk factor to HIV epidemic in Shandong province.
1.5 Methamphetamine users among FSWs were more likely to be younger, single, recruited from Sauna/bath/KTV,<18 years of age at first lifetime sex,≥2 years of duration of commercial sex, have inconsistent condom use with clients in last month, and be syphilis-infected. The syphilis-infected participants were more likely to be ever having used methamphetamine, have inconsistent condom use with clients in last month, and have been tested for HIV.
1.6 The factor of new type drug abuse has lead to higher unprotected sexual behaviors and STD infection among FSWs recruited from high-grade establishment, which was inconsistent with the traditional intervention strategies. Hence, more intervention efforts should put on the drug using FSWs recruited from the night club/bar/sauna places, at the same time, the FSWs recruited from street-based establishment shouldn't be ignored, the percentage of drug users increased from 5.0% in 2006 to 25.8% in 2008.
1.7 There are many potential risks to spread the HIV epidemic in Shandong province, such as increasing STD prevalence and un-standard STD diagnosis and treatment, comprehensive intervention should be implemented to increase their HIV/STD awareness, protected behaviors and condom promotion, et al. Different interventions strategic should be implemented according to their different demographic characteristics and behaviors of FSWs.
2. Application of respondent driven sampling in the study among female sex workers
2.1 The application of respondent driven sampling to recruit FSWs is feasible, this method has its unique advantages, and still need be improved and developed to overcome some of the limitations.
2.2 The HIV prevalence among female sex workers in Licheng District was low, but high risk sex behaviors among FSWs had been found. FSWs were the bridge population in the HIV/AIDS transmission. Its social networking features can be used to strengthen interventions.
2.3 Female sex workers have low awareness of STD/AIDS. More flexible effective health promotion should be applied in Licheng District, while the peer education, STD diagnoses and treatment, and risk awareness education should be strengthened.
2.4<20 years old and≥25 years old groups, local province residence, low establishment places and ever drug use were the risk factors associated with unprotected commercial sex in the last month. Unmarried, local province residence, <18 years of the age for first sex experience, and un-continuous condom use with client in last month were risk factors associated with drug use.
2.5 The situation of "new type" drug abuse is not optimistic, effectively policies and measures to prevent and contain "new drugs" spread should be targeted for intervention efforts.
Significance and Innovation
1. In this study, three consecutive cross-sectional surveys with consistent recruiting procedures were conducted among FSWs across 3 cities from 2006 to 2008, serological and behavior surveillance were be applied in this study with a larger sample size, which can reflect the high-risk behavioral characteristics and its trends among FSWs in Shandong province.
2. It was the first report the situation of new drug abuse and related factors in the country, the proportion of new drug abuse was 30.2% among FSWs in Qingdao city. The results showed that the association of new drug abuse, syphilis infection and unprotected sexual behaviors, further illustrated new drug abuse will be an important influent factor on HIV/STD epidemic in Shandong Province, which has important public health significance.
3. The traditional intervention strategic had pay more attention on the street-based place, ignored the role of new drug abuse among FSWs at high grade establishments, which will provide scientific basis for making intervention strategy.
4. This was the first application with RDS method to recruit FSWs in Shandong province, which will provide reference for future research in this population and other hidden populations.
艾滋病已成为全球许多国家重大的公共卫生和社会问题,艾滋病在世界范围内继续蔓延,己成为危害人类生命和健康最严重的传染性疾病之一,对社会文化、经济和政治均有重大影响。虽然目前中国艾滋病疫情处于总体低流行,但中国地域广阔,人口众多,经济发展不平衡,特定人群和部分重点地区已经出现艾滋病高流行态势,疫情正在从高危人群向一般人群扩散,性传播已经成为中国艾滋病传播的主要传播途径,在2009年新增艾滋病感染案例中占到70%以上。山东省艾滋病新报告感染者经性途径传播也呈上升趋势,2009年经性途径传播所占比例达到70.9%。性传播途径所占比例的增加有着重要的涵义,根据非洲国家的经验,当性传播成为艾滋病传播主要途径,那么它的流行速度是惊人的。因此,控制艾滋病经性传播具有重要意义。
性传播成为主要的传播方式与商业性交易的广泛存在密不可分,女性性工作者(female sex workers,FSWs)作为特殊的桥梁人群,在性病艾滋病的传播过程中起着重要的作用,了解这一高危人群的艾滋病感染状况及相关行为状况对控制艾滋病疫情有重要意义。山东省自1995年开始,对女性性工作者进行艾滋病血清学监测,经过多年的实施,为山东省女性性工作者艾滋病感染状况提供了很多的信息。同时,也暴露了血清学监测的缺点,即不能反映影响艾滋病性病传播流行的社会、行为因素,艾滋病感染的流行特征和流行因素尚不明了,具有滞后性。同时山东省艾滋病流行的各种因素广泛存在,如性病发病率的增加、流动人口的剧增、人们对性观念、性行为认识的改变,导致卖淫、嫖娼现象的增加。此外,世界卫生组织的报告认为,根据近年来毒品的流行趋势,苯丙胺类新型毒品将在一定程度上替代海洛因在亚洲及其他国家蔓延流行,但是目前,只看见西方国家在男男性行为人群中新型毒品滥用研究结果相关报到,而对于女性性工作者这一桥梁人群的新型毒品滥用情况一无所知。因此,极需在山东省开展女性性工作者这一特殊桥梁人群行为学调查。因此,我们选择在青岛、烟台和德州3个地市,连续3年在同一时间段采用同一种调查方法对女性性工作者进行调查,以期了解该桥梁人群的性病艾滋病感染状况及其相关行为特征,探索流行因素和流行趋势,对山东省今后制订艾滋病防治策略、开展行为干预提供科学依据。
同时,女性性工作者作为一个敏感的群体,由于担心受到社会排斥和公众歧视,她们不愿公开表露自己的身份,行为一般比较隐蔽,常隐匿性活动,称之为隐蔽人群。在针对隐蔽人群的调查研究中,由于缺乏对这些人群的抽样框架,对于这些难以接近人群的抽样是研究者面临的一项持续性挑战。因此,探索有效抽样方法对该人群的艾滋病防制意义重大。
同伴推动抽样(respondent-driven sampling,RDS)是近年来发展起来的一种近似概率抽样的链式推举抽样,该方法还可通过统计学调整来消除由于人们通过社会网络进行征募而出现的内在固有的偏移,为开展该人群调查并进行有代表性的估计提供了理论基础和有效途径,是一种较适合的接近隐蔽人群的抽样方法。目前,国内外已有大量关于RDS方法应用于男男性行为人群及吸毒人群的研究报告,而应用该方法调查女性性工作者的报告很少。本课题拟应用这一新技术新方法在济南市历城区开展女性性工作者调查,以期了解这一新技术新方法在该人群中的可应用性,评价其效果,同时了解当地女性性工作者的艾滋病及梅毒感染率、人口构成、高危行为情况以及与她们相联系的社会网络的信息,为当地制定艾滋病防治策略、开展行为干预提供科学依据。
研究目的
1.女性性工作者性病艾滋病感染状况及其流行因素；
2.女性性工作者性病艾滋病传播相关的行为特征及其影响因素；
3.女性性工作者性病艾滋病感染及行为变化趋势,为艾滋病疫情的估计和预测提供信息；
4.评估我省已开展的干预活动,为当地制定艾滋病防治策略、开展行为干预提供科学依据；
5.探索同伴推动抽样方法在招募女性性工作者中的应用并对其进行评价,为以后对该人群的抽样研究提供借鉴和参考。
研究方法
1.采用流行病学现场调查方法,选择青岛、烟台和德州三个调查点,连续3年在同一时间段采用分层整群抽样方法对女性性工作者进行横断面问卷调查,了解这一人群社会人口学特征、艾滋病相关知识知晓情况、性行为及其安全套使用情况、吸毒行为、求医行为、接受干预服务等信息,并采集血液进行HIV、梅毒抗体检测；使用Epidata3.0建立数据库,采用SPSS11.0统计软件进行数据的频数、均数、方差分析、卡方检验、分层分析、单因素和多因素Logistic回归分析等统计分析。
2.采用同伴推动抽样方法招募女性性工作者,调查点设置在济南市历城区疾控中心,招募过程由最初的7个“种子”开始,发给每个种子3张联系卡,由种子介绍其同伴加入研究群体,被介绍的人得到3张联系卡,又继续介绍别人,按这样的方式,推举链不断延长,样本像滚雪球一样逐渐增大,直到达到预期样本量,招募过程中采用了双重激励措施。运用RDSAT、NetDraw和SPSS 11.5分析软件进行资料的整理分析。
研究结果
1.山东省女性性工作者艾滋病高危行为变化及流行因素研究
三年共调查女性性工作者3460例,检出HIV抗体阳性者2例,HIV抗体阳性检出率为0.06%；调查对象年龄范围在15-53岁之间,年龄分布以20-24岁年龄段为主,占54.6%,婚姻状况以未婚为主,占75.9%,户籍地以本省为主,占52.0%,本省户籍的女性性工作者逐年增加,差异有显著性(P(0.001),女性性工作者文化程度有增高趋势,2006年高中及以上学历占14.7%,而2008年则占22.5%,差异显著(P<0.001)。
调查对象发生初次性行为年龄范围为11-29岁,首次商业性行为年龄范围在12-45岁之间,有47.5%的调查对象在20之前开始从事性服务工作,46.0%的调查对象从事商业性行为工作不到2年,57.8%的调查对象近一周接客数量多于7个。72.3%的FSWs最近一次与客人发生性行为时使用了安全套,2008年较2006年有了显著提高,差异有显著性(P<0.001)；最近一个月与客人发生商业性行为坚持使用安全套率不高,2006-2008年坚持使用安全套率分别为32.6%、53.6%和48.2%,差异有显著性(P<0.001)；最近一次与固定性伴发生性关系时3年平均有45.3%的FSWs使用了安全套,安全套使用率从2006年31.1%提高到2008年57.5%,使用率显著提高(P<0.001),最近一个月内与固定性伴发生性行为,三年坚持安全套使用率均很低,2006-2008年坚持使用安全套率分别为18.0%、17.6%和40.5%,差异有显著性(P<0.001)。
有45.6%的FSWs承认在最近一年出现过性病相关症状,但三年患病率未见明显改变(P>0.05),其中有72.6%的人会选择到正规医院诊疗,这一比例从2006年的38.1%上升到2008年的92.1%,差异有显著性(P<0.001),有部分女性性工作者(40.6%)在出现性病相关症状时会选择自己买药治疗,但这一比例有所下降,从2006年的54.7%下降到2008年的32.5%,差异有显著性(P<0.001)。
女性性工作者艾滋病知识知晓率有增加趋势,2006-2008年分别有75.3%、83.8%和84.6%的调查对象艾滋病知识得分≥6,女性性工作者获取艾滋病相关知识主要来源为免费宣传材料,3年平均为80.1%,其次为电视,占71.8%,2006-2008年女性性工作者获得艾滋病知识渠道变化很大,通过朋友、医生、咨询服务、宣传广告栏以及免费宣传材料几种方式获取知识比例在逐渐增加,而电视和广播所占比例在逐渐下降；最近一年接受艾滋病病毒检测比例不高,但有逐年增加趋势,2006-2008年分别为16.2%、29.8%和47.6%,差异有显著性(P<0.001)；FSWs接受过安全套发放等干预服务有逐年增加趋势,各项服务接受率均显著性提高(P<0.001)。
分层结果显示,不同场所、年龄、婚姻状况、文化程度、民族、艾滋病知识得分以及是否接受过干预服务之间安全套使用率有显著性差异。FSWs最近一个月商业性行为不坚持安全套使用与年龄两极化(<20和≥25年龄组)、较低文化水平、招募场所为路边店/站桩、出现过性病相关症状以及没有接受过安全套发放服务相关；最近一个月与固定性伴发生性行为不坚持安全套使用与≥25年龄、未婚、少数民族、出现过性病相关症状以及未接受性病检查或治疗相关。
3年共有11.2%的调查对象承认有吸毒史,其中有2.8%的对象承认在过去半年内注射过毒品。青岛、烟台和德州三个调查点的FSWs承认有吸毒行为比例分别为30.2%、2.0%和0.0%,青岛吸毒FSWs全部承认吸食的毒品为“冰毒”,有部分(4.5%)FSWs同时也吸食过“麻谷”和“K粉”。85.7%(36/42)的梅毒阳性来自于青岛监测点,因此单独分析青岛资料以了解FSWs吸毒行为及梅毒感染的相关影响因素。
青岛调查点三年共调查女性性工作者1211名,年龄分布以20-24岁年龄段为主,占41.9%,婚姻状况以未婚为主,占85.1%,户籍地以本省为主,占65.8%,文化程度以初中文化为主,占83.8%。58.1%的调查对象在20岁前开始从事性服务工作,60.2%的调查对象从事商业性行为工作不到2年。63.5%的调查对象最近一周按客数大于或等于7个。最近一个月与客人发生商业性行为坚持使用安全套率不高,仅为42.0%,最近一个月与固定性伴发生性行为时坚持使用安全套率仅为7.3%。被调查女性性工作者中,有30.2%的调查对象承认有吸毒史,其中有1.6%的对象承认在过去半年内注射过毒品,低年龄组、未婚、招募场所为桑拿/夜总会／酒吧、首次性交年龄<18岁、从事商业性行为年限≥2、最近一个月商性性行为未能坚持使用安全套以及更高的梅毒感染率是FSWs吸毒行为的危险因素。三年共有3%的被调查对象检测为梅毒抗体阳性,这一比例从2006年的1%增加到2008年6.9%,差异具有显著性(P<0.001)。梅毒感染与最近一个月商业性行为未坚持使用安全套、有吸毒史以及曾经做过HIV检测有关。
单独分析青岛FSWs调查资料了解工作场所对女性性工作者行为影响,结果显示：招募场所为站桩/路边店的女性性工作者年龄较大、文化程度更低一些,而夜总会/酒吧的女性性工作者以未婚、文化程度较高以及本省户籍为主。不同场所的女性性工作者首次商业性行为年龄、最近一周客人数量以及吸毒行为有显著差别,61.1%的夜总会/酒吧/桑拿的女性性工作者首次商业性年龄小于20岁,而这一比例在站桩/路边店以及洗脚屋/发廊女性性工作者中为49.2%和50.4%。站桩/路边店以及洗脚屋/发廊的女性性工作者最近一周客人数量较多,最近一周客人数量≥7的比例分别为95.0%和91.4%,而仅有50.4%的夜总会/酒吧/桑拿女性性工作者最近一周客人数量≥7；33.0%的夜总会/酒吧/桑拿女性性工作者有吸毒行为,而这一比例在站桩/路边店以及洗脚屋/发廊女性性工作者中仅为15.8%和28.3%。站桩/路边店以及洗脚屋/发廊的女性性工作者求医行为更不规范,2/3的女性性工作者会选择自己买药治疗或不去治疗；站桩/路边店的女性性工作者接受艾滋病相关干预服务的可及性较夜总会等高档场所低,接受免费安全套发放、同伴教育及艾滋病相关宣传材料均较夜总会/酒吧/桑拿及洗脚屋/发廊的女性性工作者的比例低,有显著性差异。多因素分析结果显示,未婚、外省户籍、初次性行为年龄(18岁是站桩/路边店的女性性工作者吸毒行为的危险因素；(25岁年龄组、初次性行为年龄<18岁、从事商业性行为年限≥2年、与商业性伴最近一个月不安全性行为以及更高的梅毒感染率是夜总会/酒吧/桑拿的女性性工作者吸毒行为危险因素；外省户籍、<20岁年龄组以及与商业性伴最近一个月不安全性行为是洗脚屋/发廊的女性性工作者吸毒行为的危险因素。夜总会/酒吧/桑拿女性性工作者梅毒感染与具有吸毒行为及曾做过HIV检测有关；而洗脚屋/发廊女性性工作者梅毒感染与从事商业性行为年限长有关。多因素分析结果显示,站桩/路边店女性性工作最近一个月与商业性伴不安全性行为与未婚和从未做过HIV检测有关；夜总会/酒吧/桑拿女性性工作者最近一个月与商业性伴不安全性行为与具有吸毒行为、从未做过HIV检测、文化程度低以及出现性病相关症状时不去治疗有关；洗脚屋/发廊女性性工作者最近一个月与商业性伴不安全性行为与具有吸毒行为以及出现性病相关症状时不去治疗有关。
2.同伴推动抽样方法在女性性工作者中的应用研究
共调查了363个女性性工作者,最长的招募链为25波。FSWs的年龄、文化程度、户籍、收入状况以及最近一个月商业性行为安全套使用等评价指标均达到了平衡。调查对象年龄最小为17岁,最大为48岁,中位数为27岁,以未婚、≥25岁年龄组、初中文化程度、外省户籍女性性工作者居多。
FSWs艾滋病性病知晓率较低,59.2%的FSWs认为“蚊虫叮咬会传播艾滋病”,41.8%不认为及时治疗性病有助于预防艾滋病,高达50.4%的FSWs存在性行为后冲洗阴道或用一些外用药可以预防艾滋病的错误认识。高达58.8%的FSWs认为自己不会感染或者不知道是否会感染艾滋病,只有12.5%的FSWs认为自己有高度感染艾滋病的危险性,仍在三分之一以上的FSWs不知道女性和男性得了性病后会有哪些症状。49.0%的FSWs为了预防性病,会定期打消炎针或吃消炎药。
首次性行为的年龄为10-28岁,首次商业性性行为的年龄为16-45岁,42.4%的FSWs从事商业性行为年限≥2年,调查对象中31.1%有一夜情或临时性伴,75.2%有固定性伴。在安全套使用方面,最近一次与商业性伴、非商业临时性伴及固定性伴发生性行为时的安全套使用率分别为88.5%、46.3%和43.6%,最近一个月与商业性伴、非商业临时性伴及固定性伴发生性行为坚持安全套使用率分别为60.8%、58.8%和22.4%。
75.8%的FSWs有饮酒史,53.4%的FSWs有吸烟史,12.7%有吸毒史,其中8.7%有注射吸毒史,均为海洛因滥用者,另外91.3%的FSWs均为吸食冰毒、K粉及摇头丸新型毒品者。只有44.9%的FSWs在最近一年接受过安全套发放、性病检查治疗、艾滋病咨询等服务,18.7%曾做过艾滋病检测。血清学检测未检出HIV抗体阳性者,梅毒感染率为5.4%。多因素Logistic回归模型结果显示,<20岁和≥25年龄组、本省户籍、低档场所以及具有吸毒行为是历城区FSWs最近一个月无保护商业性行为的危险因素。未婚、本省户籍、初次性行为年龄(18岁以及最近一个月商业性行为未坚持安全套使用是吸毒的危险因素。
结论
1.山东省女性性工作者艾滋病高危行为变化及流行因素研究
1.1女性性工作者作为艾滋病病毒传播的高危人群,其感染状况及行为状况直接反映山东省艾滋病的流行强度,通过对这一高危人群开展血清学和行为学调查结果显示,山东省女性性工作者艾滋病感染率目前总体仍处于较低水平；
1.2 2006-2008年女性性工作者艾滋病知晓率、安全套使用率以及干预服务接受率均显著增加,提示艾滋病防治工作产生一定成效。但是安全套使用率低、多性伴、吸毒行为以及性病感染比例增加等因素广泛存在,说明山东省FSWs仍面临性病艾滋病感染巨大风险；
1.3 FSWs最近一个月商业性行为不坚持安全套使用与年龄两极化(<20和≥25年龄组)、较低文化水平、招募场所为路边店/站桩、出现过性病相关症状以及没有接受过安全套发放服务相关；最近一个月与固定性伴发生性行为不坚持安全套使用与≥25年龄、未婚、少数民族、出现过性病相关症状以及未接受性病检查或治疗相关；
1.4高达30.2%的青岛市女性性工作者存在新型毒品滥用行为,单因素和多因素分析均显示吸食新型毒品与不安全性行为及梅毒感染有关,进一步说明了吸食新型毒品将是影响性病艾滋病在该类高危人群中传播的一个重要危险因素；
1.5低年龄组、未婚、招募场所为桑拿/夜总会/酒吧、首次性交年龄<18岁、商业性行为年限≥2、与商业性伴最近一个月未坚持安全套使用以及更高的梅毒感染是FSWs吸毒危险因素。FSWs梅毒感染主要与最近一个月商业性行为未坚持使用安全套、吸毒史以及曾经做过HIV检测有关；
1.6新型毒品滥用这一影响因素导致夜总会等高档场所FSWs不安全性行为及性病感染率较低档场所还要高的现象,与传统干预策略不一致,因此应加强对夜总会/酒吧/桑拿场所中具有吸毒行为的FSWs干预工作,但同时也不能忽视站桩/路边店FSWs吸毒比例也在增加,从2006年的5.0%增加到2008年的25.8%；
1.7FSWs存在多种易感染艾滋病的不安全行为,性病感染率高,就医方式还很不规范,需要实施综合干预,加大对这一人群的健康教育、行为干预及安全套推广等工作,并且针对不同人口学特征的FSWs有不同的艾滋病高危行为这一特点,制定不同的干预措施。
2.同伴推动抽样方法在女性性工作者中的应用研究
2.1运用RDS招募FSWs是可行的,有其独特的优点,同时也存在一些不足,仍需不断完善和发展。
2.2历城区FSWs艾滋病性病感染率较低,但不安全性行为广泛存在,FSWs是HIV传播的“桥梁人群”,可利用其社会网络特征来加强对这一高危人群的干预工作。
2.3 FSWs性病艾滋病知晓率较低,历城区仍需要更加灵活运用有效的健康宣传和外展服务,重视同伴教育,宣传正规途径治疗,同时加强风险意识教育。
2.4<20岁和≥25年龄组、本省户籍、低档场所以及具有吸毒行为是历城区FSWs最近一个月无保护商业性行为的危险因素。未婚、本省户籍、初次性行为年龄<18岁以及最近一个月商业性行为未坚持安全套使用是吸毒的危险因素。
2.5新型毒品滥用情况不容乐观,应采取有针对性的对策和措施,有效防范和遏制“新型毒品”的蔓延。
意义和创新
1.本研究采用生物学监测与行为学监测相结合,连续3年在同一时间段、同一调查地点采用同一种调查方法对FSWs进行调查,样本量大,代表性强,能够很好的反映山东省FSWs的危险行为特点及其变化趋势；
2.在国内首次报到FSWs新型毒品滥用现象及其影响因素,青岛FSWs新型毒品滥用比例高达30.2%,单因素及多因素分析均显示新型毒品滥用与梅毒感染、不安全性行相互关联性,进一步说明了新型毒品滥用将是影响我省性病艾滋病传播的一个重要危险因素,具有重要的公共卫生学意义；
3.传统的干预思路认为应加强路边店等低档场所FSWs的干预工作,忽略了新型毒品滥用这一影响因素而导致的夜总会等高档场所不安全性行为及性病感染率高的现象,本研究对今后制定我省艾滋病防治干预策略有重要指导意义；
4.本研究首次在山东省应用同伴推动抽样这一新技术新方法探索在女性性工作者中的应用,为以后对该人群以及其它隐蔽人群的抽样研究提供借鉴和参考。
Background
The human immunodeficiency virus (HIV/AIDS) epidemic has become a major global public health and social problems in many countries. AIDS has become one of the most serious infectious diseases to human life and health, and increasingly contributes to the erosion of civil order and economic growth. Although the AIDS epidemic in China is still in the overall low prevalence, there are significant geographic variations in HIV prevalence in difference Province, some specific groups have emerged high HIV prevalence. The epidemic is spreading from high-risk groups to the general population. Sexual contact has become the dominant modes of HIV transmission, more than 70% were infected through sexual contact in the newly reported HIV/AIDS cases in 2009. The proportion of sexual contact has also been increasing in the newly reported HIV/AIDS cases in Shandong Province,70.9% were infected through sexual contact in the newly reported HIV/AIDS cases in 2009. The increasing proportion of sexual transmission has important implications. According to the experience of African countries, when the sexual transmission became the main mode of HIV transmission, then the epidemic will rise rapidly. Therefore, the control of AIDS through sexual transmission is important.
Sexual transmission becoming a major mode of transmission was associated with the widespread presence of commercial sex trade, female sex workers (FSWs), as a special bridge groups, plays an important role in the transmission process. Hence, to understand their status of HIV infection and related behaviors will have importance meanings to control the HIV/AIDS epidemic. Since 1995, HIV serological surveillance among female sex workers was started to implement in Shandong Province, which had provide lots of information about the status of HIV prevalence among FSWs, while, it has also exposed the shortcomings of the serological surveillance, which does not reflect the social and behavioral factors of AIDS epidemic, those risk factors associated with HIV/STD infection and high risk behaviors are not clear. At the same time, there are many potential risks to spread the epidemic in Shandong province, such as increasing STD prevalence, increasing mobility population, broader sexual freedom with more tolerant views, concurrent with the increasing of commercial sex in Shandong Province. In addition, the World Health Organization (WHO) reported that methamphetamine use will become a major public health issue in the world, and will spread to replace heroin in some extent in Asia and other countries. But for now, Methamphetamine use and related risk factors has been only reported among MSM in western countries, and few studies have investigated methamphetamine use among FSWs. Thus, behavioral investigation among FSWs should be conducted in Shandong province to understand their status of HIV/STD prevalence and risk factors. Therefore, three consecutive cross-sectional surveys with consistent recruiting procedures were conducted among FSWs across 3 cities from 2006 to 2008, in order to explore their status of HIV/STD infection and behavioral characteristics, to understand HIV-related behavior change trends and assess their potential roles in the HIV epidemic, which will be helpful for HIV/AIDS control in the future.
Female sex workers is also called hidden populations, are a sensitive group, they don't want to reveal their identity in public for the reason of discrimination. It is a continuing challenge for researchers to get a representative sample among those hidden populations. Therefore, exploring the effective sampling method will be special meaning for AIDS control.
Respondent driven sampling is a new form of chain referral sampling method to sample a hidden population, it also claims to produce an unbiased indicator for population estimates through special statistical soft to analyze the variability of indicators and thereby compute standard errors for population estimates. RDS has been applied in many research programs to sample hard-to-reach and hidden populations such as IDUs and MSM, however, the RDS method has not been widely applied for recruiting FSWs. This study was conducted to recruit FSWs using RDS method to explore and evaluate application of respondent driven sampling in the recruitment of female sex workers, and to investigate demographic characteristics, their status of HIV/STD infection, their social network information, and high risk behaviors of female sex workers, and offer scientific evidence for developing intervention strategy.
Objects
1. To understand HIV/STD prevalence and risk factors among female sex workers.
2. To understand HIV-related behavioral characteristics and risk factors among female sex workers.
3. To understand HIV/STD prevalence and behavioral change trends among female sex workers, and provide information for the HIV/AIDS epidemic estimation.
4. To evaluate intervention effect, and provide scientific basis for making intervention strategy.
5. To explore and evaluate application of respondent driven sampling in the recruitment of female sex workers, and provide reference for future research in this population.
Methods
1. Three consecutive cross-sectional surveys with consistent recruiting procedures were conducted among FSWs across 3 cities in 2006,2007 and 2008, respectively. Questionnaire-based interviews provided demographic and social information, sexual behaviors and condom use, drug use behavioral information, HIV knowledge and perceptions, ever had STD-related symptoms, and ever received HIV-related services. Blood samples were collected from all participants to test their status of HIV and syphilis prevalence. Survey data were recorded with EpiData software. SPSS11.0 software was applied for all statistical analyses, such as mean, variance analysis, chi-square test, stratified analysis, univariate and multivariate Logistic regression analysis.
2. Respondent driven sampling was used to recruit female sex workers, seven seeds were recruited through the local key informants to participate in the study. After the seeds completed the interview, each of them was given three coupons for recruiting their peers into the study. Three coupons for referring peers were given to the participants when they finished the interview and the sample collection. The desired sample size will be gotten by this chain-referral sampling method. All new recruits were offered a dual incentive, one for completing the interview and on for recruiting. RDSAT, NetDraw and SPSS 11.5 software were applied for data analysis.
Results
1. The results of high risk behavioral change research among FSWs in Shandong Province
3,460 participants in total were investigated in the three years, of the participants, 2 were HIV-infected (1 in 2006 and 1 in 2008).54.6% were 20-24 years of age,75.9% were unmarried, and 52.0% coming from local province. The proportion of FSWs coming from local province was increasing, there was a significant difference (P<0.001), and education level of FSWs was increasing with 14.7% received high school or high education in 2006 and 22.5% in 2008.
The age of first sex experience was from 11 to 29 years old, and the age of first commercial sex was from 12 to 45 years old.47.5% started sex work<20 years of age, 46.0% had<2 years of sex work experience, and 57.8% had≥7 paying clients in the past week.72.3% reported condom use with client in the last sex behavior, there was a significant difference compared 2008 to 2006 (P<0.001). The rates of consistent condom use for FSWs with clients in the last month were 32.6%,53.6%, and 48.2%, respectively. there was a significant difference(P<0.001).45.3% reported condom use with regular partners in the last sex behavior, there was a significant increase compared 31.1% in 2006 to 57.5% in 2008(P<0.001). The rates of consistent condom use for FSWs with regular partners in the last month were 18%,17.6%, and 40.5% in 2006,2007, and 2008, respectively, there was a significant difference (P<0.001).
45.6% of the FSWs reported ever appear STD-related symptoms, but there wasn't a significant difference in the three years (P>0.05), of which 72.6% will choose hospital to treatment, the proportion was increasing from 38.1% in 2006 to 92.1% in 2008, there was a significant difference (P<0.001). Some of FSWs may choose to treat by buy medicine from shopping, but the proportion decreased, from 54.7% in 2006 to 32.5% in 2008, the difference was significant (P<0.001).
The HIV/AIDS knowledge scores≥6 among FSWs were 75.3% in 2006, 83.8% in 2007, and 84.6% in 2008, the major mode for FSWs to access HIV-related knowledge was free promotional materials, accounting for 80.1%, followed by television, accounting for 71.8%. The proportion of FSWs access HIV-related knowledge channels was vary widely, the proportion of by friends, doctors, consulting services, advertising columns, and free publicity material were gradually increase, while the proportion of by television and radio gradually decline. The proportion of ever received HIV test was not high, but there was a rising trend with 16.2% in 2006, 29.8% in 2007,and 47.6%in 2008, the difference was significant (P<0.001).The proportion of ever received intervention service was increasing, there is a significant difference in each intervention item(P<0.001)
Stratified analysis results showed that Different places, age, marital status, education level, ethnicity, AIDS knowledge score and whether ever received intervention services were have difference condom use rate. Unconsistent condom use with clients in the last month was independently associated with being<20 or≥25 years of age, lower education, being recruited from Non-venue based establishments, self-reported STD-related symptoms, and never received free condom. Unconsistent condom use with regular sex partners in the last month was independently associated with being≥25 years of age, being single, minority ethnicity, self-reported STD-related symptoms and never received STD examination and/or treatment.
Of the participants,11.2% reported ever using illicit drugs with 2.8% ever injecting drugs. The proportion of ever using drug was 30.2% in Qingdao,2.0% in Yantai, and 0.0% in Dezhou, respectively. All drug using FSWs in Qingdao admitted taking methamphetamine, and some (4.5%) FSWs also smoked "Magu" and "K powder". Most of FSWs (85.7%) who had infected syphilis were coming from Qingdao survey site, so the data from Qingdao was analyzed separately, in order to understand the risk factors of drug using and syphilis infection.
1211 eligible participants were investigated in Qingdao city in the three years, 41.9% were 20-24 years of age,85.1% were single,65.8% were Shandong residents, and 83.8% received middle school of education. Of 1211participants, nearly half had first lifetime sex at <18 years of age; 58.1% started sex work at <20 years of age; 60.2% only had <2 years of sex work experience, two-thirds had≥7 clients in the past week. Only 7.3% reported consistent condom use with regular sex partners and 42% with clients in the last month.30.2% reported using methamphetamine in the last 6 months with 1.6%(6) of the methamphetamine users ever injecting. Analysis results showed, methamphetamine users were more likely to be younger, single, recruited from Sauna/bath/KTV,<18 years of age at first lifetime sex,≥2 years of duration of commercial sex, have inconsistent condom use with clients in last month, and be syphilis-infected. Of 1211 participants,3% were syphilis-infected, with a dramatic increase from 1% in 2006 to 6.9% in 2008. The syphilis-infected participants were more likely to be ever having used methamphetamine, have inconsistent condom use with clients in last month, and have been tested for HIV.
Female sex workers are at greater risk of experiencing harm from their club drug use, since clients often solicit FSWs in different venues to share drug and sex experiment. Hence, separate analyze was taken for the Qingdao data, in order to assess the impact of commercial sex venues on the syphilis and methamphetamine epidemics among FSWs. The results showed that The FSWs recruited from street-based entertainment were more likely to be older age and lower education level, while, FSWs recruited from night clubs or bars were more likely to be unmarried, higher education level and local residence. There were significant difference on the age of first commercial sex, the number of clients in the past week and drug behaviors, At the venue of saunas, night clubs or bars,61.1% started sex worker at <20 years of age, and the proportion were 49.2% at the venue of street-based entertainment and 50.4% at the venue of hair/beauty salons. Those FSWs recruited from street-based entertainment and hair/beauty salons had higher number of clients in the past week, the proportion of number of clients in the past week≥7 were 95.0% and 91.4%, respectively, while only 50.4% at the venue of saunas, night clubs or bars.33.0% FSWs recruited from saunas, night clubs or bars reported using methamphetamine, the proportion were 15.8% in street-based entertainment and 28.3% in. More than two third of FSWs recruited from street-based entertainment and hair/beauty salons may buy medicine from a pharmacy or don't cure if they felt uncomfortable. The FSWs recruited from street-based entertainment had lower proportion to receive intervention service than night clubs, had a lower proportion of ever received free condom, peer education and HIV-related materials, there was a significant difference.
In the multivariate analysis, the street-based methamphetamine users were more likely to be single, not recruited from Shandong Province and have first lifetime sex <18 years of age. The night clubs/bars/sauna-based methamphetamine users were more likely to have their first lifetime sex<18 years of old, have had sex work≥2 years, younger age, had unprotected sex with clients in the last month and syphilis-infected. The hotels/hair/beauty salons-based methamphetamine users were more likely to be recruited from non-Shandong other provinces,<20 years of age and had unprotected sex with clients in the last month.
In multivariate analysis, the night clubs/bars/sauna-based FSWs with syphilis infection were more likely to be methamphetamine users and have already attended HIV testing; the hotels/hair/beauty salons-based FSWs with syphilis infection were more likely to have had sex work≥2 years and syphilis infection.
In multivariate analysis, the street-based FSWs who reported had unprotected commercial sex were more likely to have not received HIV testing and being single; The night clubs/bars/sauna-based FSWs who reported had unprotected commercial sex were more likely to have not received HIV testing, less education, had unprotected sex with clients in the last sex, be methamphetamine users and not sought any treatment for their STD symptoms; the hotels/hair/beauty salons-based FSWs who reported had unprotected commercial sex were more likely to be methamphetamine users and not sought any treatment for their STD symptoms.
2. The results of application of respondent driven sampling in the study among female sex workers
In total 363 participants, were recruited for the study. The longest recruitment tree had 25 recruitment waves, the evaluation variables including age, educational level, residence, income, and condom use with commercial sex partners in the last month have reached equilibrium. Of the total 363 participants, the youngest participant was 17 years and the oldest was 48 years old, the median age was 27 years. Most of the participants were unmarried,≥25-year-old age group, junior middle school education and coming from other provinces.
The estimated population proportion has a low awareness of AIDS,59.2% of participants think mosquito bites can spread AIDS,41.8% do not think that timely treatment can help prevent AIDS, a high proportion of 50.4% think that washing the vagina after having sex or using some external use the mistake can prevent AIDS. Up to 58.8% of the participants think they will not or do not know whether infect AIDS infect, only 12.5% perceived themselves will have a high risk of HIV infection. More than one third of the FSWs do not know the symptoms of STDs among females and males.49.0% regularly use anti-inflammatory medicine in order to prevent sexually transmitted diseases.
The age for the first sex experience ranged from 10 to 28 years old, the age for initiating commercial sex ranged from 16 to 45 years old.42.4% of participants have the duration of being a sex worker≥2 years.
The proportions who had non-regular non-paying partners and regular partners was 31.1% and 75.2%. The condom use rate in the last sex with clients, non-regular not-paying partners and regular partner were 88.5%,46.3% and 43.6%, and the condom use rate in the last month were 60.8%,58.8% and 22.4% respectively.
The estimated population proportions who had drinking history was 75.8% and 53.4% had smoking history.12.7% had history of ever using drug, among which only 8.7% had history of injection heroin drug use, while 91.3% of FSWs were taking new type drug including methamphetamine, K powder and ecstasy. Only 44.9% of FSWs had ever received condom distribution, STD examination and treatment, or AIDS counseling and other services in the last year, and 18.7% had ever taking HIV testing. None of the participants were HIV-positive, and the syphilis prevalence was 5.4%.Multivariate Logistic regression model showed that< 20 and≥25 years old groups, Shandong province residence, low establishment-based places and ever drug use were risk factors associated with unprotect commercial sex behaviors in the last month. Unmarried, Shandong province residence,<18 years old of the age for the first sex experience, and not continuous condom use with clients in the last month were risk factors associated with drug abuse.
Conclusions
1. High risk behavioral change research among FSWs in Shandong Province
1.1 Female sex workers were the high risk population in the HIV/AIDS epidemic, their status of HIV infection and behaviors can reflect the epidemic in Shandong province. The results of this study showed that the HIV prevalence of FSws was still at a relatively low level in Shandong province.
1.2 This study showed an increasing proportion on the AIDS awareness, condom use, and intervention services coverage from 2006 to 2008, which indicated the effectiveness of AIDS prevention and control in some extent. Nevertheless, there are many potential risks to spread the HIV epidemic in Shandong province, such as low condom use, multiple sex partners, drug use, and increasing STD prevalence.
1.3 The FSWs who reported had unprotected commercial sex in the last month were associated with <20 and≥25 age groups, lower education level, recruited from street-based establishment, ever having STD-related symptoms and never received free condoms. Inconsistent condom use with regular partners in the last month was independently associated with≥25 years age, single, minority, ever having STD-related symptoms and never received STD examination and treatment.
1.4 Up to 30.2% of female sex workers in Qingdao were methamphetamine users, univariate and multivariate analysis results showed that methamphetamine use was associated with unprotected sex behaviors and syphilis infection, which further illustrates "new type" drugs will be an important risk factor to HIV epidemic in Shandong province.
1.5 Methamphetamine users among FSWs were more likely to be younger, single, recruited from Sauna/bath/KTV,<18 years of age at first lifetime sex,≥2 years of duration of commercial sex, have inconsistent condom use with clients in last month, and be syphilis-infected. The syphilis-infected participants were more likely to be ever having used methamphetamine, have inconsistent condom use with clients in last month, and have been tested for HIV.
1.6 The factor of new type drug abuse has lead to higher unprotected sexual behaviors and STD infection among FSWs recruited from high-grade establishment, which was inconsistent with the traditional intervention strategies. Hence, more intervention efforts should put on the drug using FSWs recruited from the night club/bar/sauna places, at the same time, the FSWs recruited from street-based establishment shouldn't be ignored, the percentage of drug users increased from 5.0% in 2006 to 25.8% in 2008.
1.7 There are many potential risks to spread the HIV epidemic in Shandong province, such as increasing STD prevalence and un-standard STD diagnosis and treatment, comprehensive intervention should be implemented to increase their HIV/STD awareness, protected behaviors and condom promotion, et al. Different interventions strategic should be implemented according to their different demographic characteristics and behaviors of FSWs.
2. Application of respondent driven sampling in the study among female sex workers
2.1 The application of respondent driven sampling to recruit FSWs is feasible, this method has its unique advantages, and still need be improved and developed to overcome some of the limitations.
2.2 The HIV prevalence among female sex workers in Licheng District was low, but high risk sex behaviors among FSWs had been found. FSWs were the bridge population in the HIV/AIDS transmission. Its social networking features can be used to strengthen interventions.
2.3 Female sex workers have low awareness of STD/AIDS. More flexible effective health promotion should be applied in Licheng District, while the peer education, STD diagnoses and treatment, and risk awareness education should be strengthened.
2.4<20 years old and≥25 years old groups, local province residence, low establishment places and ever drug use were the risk factors associated with unprotected commercial sex in the last month. Unmarried, local province residence, <18 years of the age for first sex experience, and un-continuous condom use with client in last month were risk factors associated with drug use.
2.5 The situation of "new type" drug abuse is not optimistic, effectively policies and measures to prevent and contain "new drugs" spread should be targeted for intervention efforts.
Significance and Innovation
1. In this study, three consecutive cross-sectional surveys with consistent recruiting procedures were conducted among FSWs across 3 cities from 2006 to 2008, serological and behavior surveillance were be applied in this study with a larger sample size, which can reflect the high-risk behavioral characteristics and its trends among FSWs in Shandong province.
2. It was the first report the situation of new drug abuse and related factors in the country, the proportion of new drug abuse was 30.2% among FSWs in Qingdao city. The results showed that the association of new drug abuse, syphilis infection and unprotected sexual behaviors, further illustrated new drug abuse will be an important influent factor on HIV/STD epidemic in Shandong Province, which has important public health significance.
3. The traditional intervention strategic had pay more attention on the street-based place, ignored the role of new drug abuse among FSWs at high grade establishments, which will provide scientific basis for making intervention strategy.
4. This was the first application with RDS method to recruit FSWs in Shandong province, which will provide reference for future research in this population and other hidden populations.
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