The authors assessed the relative impact of structural and social influence interventions on reducing sexually transmitted infections (STIs) and HIV risk behavior among female sex workers in the Philippines (N = 897). Four conditions included manager influence, peer influence, combined manager-peer influence, and control. Intervention effects were assessed at the establishment level in multilevel models because of statistical dependencies among women employed within the same establishments. Control group membership predicted greater perceived risk, less condom use, less HIV/AIDS knowledge, and more negative condom attitudes. Combination participants reported more positive condom attitudes, more establishment policies favoring condom use, and fewer STIs. Manager-only participants reported fewer STIs, lower condom attitudes, less knowledge, and higher perceived risk than peer-only participants. Because interventions were implemented at the city level, baseline and follow-up city differences were analyzed to rule out intervention effects due to preexisting differences. Keywordsfemale commercial sex workers; HIV/AIDS risk; social influence intervention; STIs; condom use Female commercial sex workers (FCSWs) are at high risk of transmitting HIV and sexually transmitted infections (STIs). This is particularly true in Asian countries, such as the Philippines. For instance, a recent large survey showed an exceptionally high prevalence rate of chlamydiosis among Filipino FCSWs ranging from 27% to 36% (World Health Organization, 2002). According to the survey, the principal mode of transmission was heterosexual contact (World Health Organization, 2002 HIV prevention has traditionally focused on using cognitive-behavioral individually oriented approaches to induce beneficial changes in the individual's attitudes, knowledge, and behaviors regarding HIV, with little attention to important structural-environmental factors that also account for individual behaviors (O'Leary, Holtgrave, Wright-DeAguero, & Malow, 2003). However, individualized prevention strategies may be less than optimal in changing risky behaviors in such situations as those of commercial sex workers (Bandura, 1982(Bandura, , 1987Ford et al., 1996;O'Leary & Martins, 2000;Pleck, Sonenstein, & Ku, 1990). Social-structural factors, such as extreme poverty, which characterizes Filipino FCSWs, and a lack of support by employers as well as customers may impede safe sex practices; satisfying the customer's desire for sex without a condom may have become almost mandatory in maintaining one's livelihood and reducing conflicts with employers, despite the FCSW's personal perception of risk. Peers may also exert an influence on safe sex behaviors when FCSWs are based within establishments. Therefore, economic factors, peer influences, and employment-or employerrelated factors may have become a major barrier against consistent condom use ( Morisky et al., 1998;Outwater et al., 2000).In contrast, a perception of a supportive attitude by one's employer toward cond...

This study examines the effects of a multi-level social action-based theory (SABT) intervention to increase HIV testing and consistent condom use among female commercial sex workers (FCSWs). Respondents in four socio-demographically similar Philippine cities received an SABT intervention based on: (1) peer influence; (2) manager training; (3) combined peer/manager influence; or (4) usual care (control condition). HIV testing increased 86% from baseline (N = 980) to follow-up (N = 903), and was significantly associated with higher HIV/AIDS knowledge, lower probability of contracting HIV and increased condom use. After adjusting for socio-demographic, HIV knowledge and perceived control variables, FCSWs in the manager training and combined peer/manager conditions were significantly more likely to engage in consistent condom use. Mediational analyses revealed higher HIV/AIDS risk perceptions and a supportive work environment related to increased condom use. These findings support a growing body of research suggesting the need for multi-level sexual risk reduction interventions among FCSWs.

The HIV/Sexually Transmitted Infection (STI) risk associated with alcohol use between female commercial sex workers (FCSWs) and their customers has been understudied. We examined this relationship for 1,114 FCSWs aged 15-54 with data collected during the baseline study period (1994 to 1998) in four southern provinces of the Philippines. Two alcohol-related risk situations during commercial sex episodes were examined: prior alcohol use by an FCSW and perceived intoxication in a customer. The influence of sociodemographic variables on sexual risk behaviors was also studied. Multiple sexual risk behaviors were observed with more frequency for FCSWs if alcohol was used before commercial sex or if the episode involved a customer perceived to be intoxicated. Forty-two percent of FCSWs who had sex with an intoxicated customer were STI positive, significantly more than FCSWs who did not have sex with an intoxicated customer (28%, p < .01). Similar significant differences were found for FCSWs who did not consume alcohol before having sex and were STI positive (29%) versus FCSW who did consume alcohol before sex and were STI positive (33%, p < .01). Our analyses reinforce accumulating evidence in the field that sexual risk reduction interventions need to go beyond the behaviors of individual FCSWs to meet the layering of risks such as observed in this study. Multilevel strategies targeting customer substance use and other situational and structural factors have proven to be pivotal mediators in our other research with this population. These experiences and the limitations of this study are discussed.

Injection risk practices and unprotected sex between injection drug users (IDUs) and their sexual partners are responsible for a high proportion of AIDS cases and new HIV infections in the United States. The purpose of this study was to investigate the links between drug use behaviors and psychosocial factors with high-risk sexual behaviors among male and female IDUs. Understanding the determinants of sexual risk practices among drug users can lead to the development of more effective programs to prevent sexual HIV and STD transmission. This study enrolled a community sample of 101 IDUs (males = 65, females = 36), primarily African American and unemployed, who injected drugs and had unprotected sex in the past 3 months. The sample was categorized into highest sexual risk (multiple partners and intercourse without condoms) and lower sexual risk subgroups. Univariate analyses showed that IDUs at highest sexual risk had lower sexual risk reduction self-efficacy (p =.01) and were more likely to be African American (p =.02). Drug users at highest sexual risk also used noninjected cocaine and crack more frequently (p =.05), were less likely to inject heroin (p =.04), and tended to more often inject cocaine (p =.05). IDUs at highest sexual risk also tended to more often use crack and methamphetamines. Logistic regression analyses showed that injecting cocaine or crack, sexual risk reduction self-efficacy, and race were independent predictors of sexual risk behavior levels. Sexual risk reduction programs for this population are needed, with HIV prevention programs tailored to specific IDU risk reduction needs.

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