Findings from Encontros: A Multi-Level STI/HIV Intervention To Increase Condom Use, Reduce STI, and Change the Social Environment among Sex Workers in Brazil

"Sexually transmitted infection (STI)/HIV prevention programs which do not modify social-structural contexts that contribute to risk of STI/HIV may fail to bring about improvements in health, particularly among groups who experience discrimination and exclusion from public life."

The study followed sex workers in the Encontros intervention in Corumbá, Brazil, in order to gather findings on this multi-level intervention, including improved clinical care and community mobilising strategies to modify social-structural factors that shape sexual behaviour, both  improved condom use and reduced incident STI. [Footnotes are removed throughout.]

"Intervention design was informed by review of international best practices and extensive formative research, including mapping sex work venues, stakeholder interviewers (brothel/bar owners, moto-taxi drivers, public health officials), focus groups with sex workers in a variety of venues, and in-depth-interviews with sex workers and clients. [Encontros] also developed the intervention using the ecological model combining strategies to engage sex workers on an individual level through participation in STI/HIV testing experiences, on an inter-personal level through peer-education and counseling, and on a community level through outreach, workshops, and social activities" coupled with work to make health services more accessible, including "extending clinic hours to provide expanded, holistic services for STI/HIV prevention, diagnosis, and treatment, as well as reproductive health services and intensive training to create a sex worker friendly environment. Educators conducted outreach and distribution of condoms and educational materials designed by the Ministry of Health to reduce sex work-associated stigma." Project activities engaged participants through their design, stimulating dialogue around sex work, discrimination, human rights, and prevention, specifically through workshops, trainings, and events. A number of workshops offered skills-based training, "from soap, candle, and chocolate making to theater and fashion design", and resulted in "hot pink" parties, "cultural showcases for the sex workers that occurred at the city’s cultural center, a public space where those attending included the general public, public officials, family members, and university students," to reduced stigma and forge broad partnerships and links to the community.

Through both convenience and snowball sampling to reach as many sex workers in the area as possible (begun through sex work peer educator recruiters), the study included 420 men, women, and transvestites who were 18 years or older, self-identifying as sex workers. "Enrollment and follow-up visits included administration of a structured, interviewer-administered questionnaire, STI/HIV prevention counseling, a clinical exam, and collection of urine and blood samples for STI testing."

Questionnaires measured participation and interaction with peer educators. In sexual health exams, questions were asked about sexual practices in working interactions and condom use. "We also measured social environmental factors hypothesized to enable protective behaviors, including perception of mutual aid, trust, and support among sex workers (social cohesion); participation in social networks; and access to and management of social and material resources (including purchasing of household and personal goods and access to services, such as banking and health insurance)."

Results intended to address the social-structural context that influences an individual’s behaviour in order to bring about sustained behaviour change. Of the 474 original responders, 79% came to the first follow-up visits, 45% completed all 5 visits. (Mobility - including leaving the area or leaving the profession - contributed to much of the decrease.) The study found that "exposure to the intervention was protective against incident STI and resulted in increased reporting of consistent condom use:

• “Inverse probability weighted estimates indicate that participation in the intervention was associated with a higher odds of consistent condom use with new clients (OR:1.6, 95%CI: 0.9-2.8), regular clients (OR:1.9, 95%CI:1.1-3.3), and nonpaying partners (OR:1.5, 95%CI:0.9-1.5).”
• “Odds of an incident STI were reduced for the exposed group compared to unexposed participants (OR:0.46, 95% CI:0.2-1.3)"

"A]s hypothesized, project exposure was associated with a significant increase (of 0.3 standard deviations) in participation in networks, both in the entire cohort and among those reporting below median participation in networks at enrollment. Additionally, participants reported a significant increase in perceived social cohesion as compared to non-participants among study subjects reporting below median perceived social cohesion at enrollment. There was no relationship between participation and access to social and material resources."

In their concluding remarks, researchers suggest that an ideal design, if cost is not a factor, would be a randomised trial instead of the prospective cohort used here. They recommend: "[D]eeper investigation regarding the pathways of effect - how participation changes the social environment to improve health - will improve our understanding of the community-level processes that shape behavior and inform future interventions.”