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Background: Multilevel analytical techniques are being applied in condom use research to ensure the validity of investigation on environmental/structural influences and clustered data from venue-based sampling. The literature contains reports of consistent associations between perceived gatekeeper support and condom use among entertainments establishment-based female sex workers (FSWs) in Guangxi, China. However, the clustering inherent in the data (FSWs being clustered within establishment) has not been accounted in most of the analyses. We used multilevel analyses to examine perceived features of gatekeepers and individual correlates of consistent condom use among FSWs and to validate the findings in the existing literature. Methods: We analyzed cross-sectional data from 318 FSWs from 29 entertainment establishments in Guangxi, China in 2004, with a minimum of 5 FSWs per establishment. The Hierarchical Linear Models program with Laplace estimation was used to estimate the parameters in models containing random effects and binary outcomes. Results: About 11.6% of women reported consistent condom use with clients. The intraclass correlation coefficient indicated 18.5% of the variance in condom use could be attributed to their similarity between FSWs within the same establishments. Women's perceived gatekeeper support and education remained positively associated with condom use (P < 0.05), after controlling for other individual characteristics and clustering. Conclusions: After adjusting for data clustering, perceived gatekeeper support remains associated with consistent condom use with clients among FSWs in China. The results imply that combined interventions to intervene both gatekeepers and individual FSW may effectively promote consistent condom use. DOI: 10.1097/OLQ.0b013e3181e1a2b2

Background and Objective: Alcohol use has been suggested to interfere with condom use and to increase sexual risk behaviors. However, data on the prevalence of this practice among female sex workers and its association with condom use and sexually transmitted infections (STIs) are limited. Methods: Data were collected through the baseline survey of an HIV prevention project among 454 establishment-based female sex workers in Guangxi, China, in 2004. Both global association and situational analysis were performed using 2 measures of alcohol use (alcohol intoxication and drinking alcohol before having sex with a client). Multiple logistic regression analyses were performed to examine the association of alcohol use with women's condom use and STIs. Results: One-third of women reported being intoxicated with alcohol at least once a month during the previous 6 months, and about 30% reported using alcohol before having sex with clients. In comparison with women who did not use alcohol before engaging in sex with clients, women who did so reported significantly less consistent condom use and higher rates of both current STIs and a history of STI. However, alcohol intoxication was not associated with condom use and STIs. These findings indicate event-specific rather than global associations of alcohol use with inconsistent condom use and STIs. Conclusion: Alcohol use before commercial sex is associated with unprotected sex and increased risk for STIs. Interventions that address both alcohol use and HIV risk behaviors in the context of commercial sex may have a great impact in preventing the spread of HIV in China. DOI: 10.1097/OLQ.0b013e3181e2118a

Objectives and Background: Condom use within the context of commercial sex work is a complex issue. Drawing on a hypothesized theoretical model that combines concepts from the health belief model and social cognitive theory, this study examines the complex relationships between multiple levels of determinant factors of condom use with clients among female sex workers in China. Methods: Data were collected through the baseline survey of an HIV prevention project among 454 establishment-based female sex workers in a rural county of Guangxi, China in 2004. Path analysis was performed to test the hypothesized model that specifies relationships between all observed variables. Results: Within the context of this study's model, STD/HIV knowledge and condom use skills were related to self-efficacy which in turn related to condom use. Susceptibility/severity was related to perceived benefits of unprotected sex. Perceived benefits were in turn inversely related to condom use. STD/HIV knowledge, condom use skills, and susceptibility/ severity had no direct effect on condom use. Their effects on condom use were mediated by self-efficacy and perceived benefits. Self-efficacy was not associated with perceived benefits of unprotected sex. Perceived establishment-level support was positively related to condom use. Conclusions: Self-efficacy, perceived benefits of unprotected sex. and perceived establishment-level support are proximate determinants of condom use among female sex workers. Future HIV prevention interventions should integrate these factors into conceptual frameworks.

Objective: To examine the influence of environmental support on HIV prevention behaviors (i.e., condom use behaviors, communication and intention, and HIV/STD testing) among female sex workers (FSWs) in China. Methods: A cross-sectional survey was administered among 310 FSWs recruited from entertainment establishments in Liuzhou City in Southwest China in 2006. Sex workers were asked about their demographic and working characteristics and their HIV prevention behaviors. Environmental support was measured by a scale consisting of 8 items regarding condom availability, managerial, and social support of HIV prevention (Cronbach [alpha] = 0.73). Results: After adjusting for demographic and working characteristics, condom use self-efficacy and knowledge, environmental support was strongly associated with following HIV prevention behaviors: overall consistent condom use (aOR = 1.7, 95% CI = 1.3, 2.3), consistent condom use in the last 3 sexual acts (aOR = 1.5, 95% CI = 1.1, 2.0), intention to use condoms consistently (aOR = 1.6, 95% CI = 1.1, 2.2), and HIV testing (aOR = 1.6, 95% CI = 1.1, 2.2). Conclusion: Environmental support is a significant predictor of HIV prevention behaviors among establishment-based FSWs in China. The data underscore the importance of developing environmental/structural HIV/STD interventions for FSWs. Condoms need to be easily accessible in the establishments. Gatekeepers need to be educated to create a supportive environment for condom use and HIV prevention.

Background and Objective: Men who pay for sexual services are at increased risk for HIV/sexually transmitted disease. Data on the sociodemographic and behavioral characteristics of such men in China are limited. Study Design: Two cross-sectional surveys, using similar instruments, were completed among Chinese migrants in Beijing, Shanghai, and Nanjing in 2002. A total of 1304 rural-to-urban migrant men from community settings ('community sample') and 465 migrant men attending sexually transmitted disease clinics ('STD clinic sample') were included in the current study. Results: Ten percent of men in the community sample and 32.7% of men in the STD clinic sample reported having ever paid for sex. Nearly 20% of clients from the community sample and 60% of clients from the STD clinic sample reported a history of STDs. For both the community and STD clinic samples, working at industrial or construction sectors, multiple sexual partners, regular sex partner having sex with others, and a history of drug use were associated with being a male client. In addition, perceived peer sexual risk and perceived vulnerability to STD were associated with being a male client in the community sample, and a history of STD and being tested for STD/ HIV were associated with being a male client in the STD sample. Conclusion: Male migrants who paid for sex in China were vulnerable to HIV/STDs. HIV prevention efforts should target young migrant men who work at factory and construction sectors. STD clinics may be important sites for outreach and intervention efforts among male clients.

Background and Objective: Vaginal douching has been hypothesized to increase a woman's risk for human immunodeficiency virus (HIV) infection. However, data on the prevalence of this practice and its association with condom use and sexually transmitted infections (STIs) are limited. Study: A cross-sectional survey among 454 female sex workers (FSWs) in a Chinese county. Results: Vaginal douching was reported by 64.7% of the women. the prevalence of self-reported history of STI and that of current STI was 19.4% and 41.5%, respectively. Fifteen percent of the women reported consistent use of condoms with their clients and 8.4% with their regular partners. Vaginal douching was significantly associated with decreased use of condoms (with clients: OR = 0.31; with regular partner(s): OR = 0.22) and increased rate of self-reported STI history (OR = 1.95). However, there was no direct relation between douching and current STI. Over one third of the women believed that douching can prevent STI/HIV. Conclusion: Vaginal douching exposes FSWs to a high risk of STI/HIV. Medical professional and public health workers should correct women's misconception about the effectiveness of douching and discourage women from douching through educational activities.

Objective: The objective of this study was to assess the potential role of gatekeepers of establishments in promoting condom use among female sex workers (FSWs) in China. Goals: The goals of this study were to explore FSWs' perceptions of gatekeeper attitudes and support for condom use, and to assess their association with FSWs' practice, communication, intention, proper use, knowledge of correct use, and perceptions related to condom use. Study: The authors conducted a cross-sectional study among 454 establishment-based FSWs in one Chinese county. Results: Perceived gatekeeper support for condom use was low among FSWs. Perceived support was positively associated with condom use communication with sexual partners, condom use frequency and intention, but not associated with proper condom use among FSWs. Perceived support was significantly associated with most condom use-related perceptions (e.g., self-efficacy of condom use, barriers to condom use, and perceived peer condom use) among FSWs. Conclusions: Healthcare professionals should work with gatekeepers to create a supportive local environment for condom use in sex work establishments. Gatekeepers need to clearly articulate their support for condom use to the FSWs. Training and skill acquisition regarding correct use of condoms among FSWs will be necessary.

Objective: The objective of this study was to address the role of heterosexual transmission of HIV in China. Goal: The goal of this study was to explore the prevalence of unsafe sex and the likelihood of HIV spread heterosexually from core populations to others. Study: The authors conducted a review of behavioral studies. Results: Drug users were more likely to be involved in higher-risk sexual behaviors than were those who abstained from using drugs. Most female drug users (52-98%) reported having engaged in commercial sex. Most female sex workers (FSWs) and individuals with sexually transmitted diseases (STDs) had concurrent sexual partners. Many continued to have unprotected sex after noticing STD symptoms in themselves or their sexual partners. From 5% to 26% of rural-to-urban migrants had multiple sexual partners and 10% of males patronized FSWs during migration. Conclusions: Factors such as high rates of FSW patronage, low rates of condom use during commercial sex, having sex with both commercial and noncommercial sexual partners, and high rates of STD infection may promote a heterosexual epidemic in China.

Objective: To examine the evolution of risk behaviors over 2 years among a community-based cohort of low-income African American preadolescents and young adolescents enrolled in a randomized trial of an acquired immunodeficiency syndrome risk reduction intervention. Design: Longitudinal, community-based cohort. Setting: Nine recreation centers serving 3 public housing developments. Subjects: Three hundred eighty-three African American youths aged 9 through 15 years at baseline. Interventions: Frequency distributions, [chi square] analyses, and regression analyses regarding 10 risk behaviors were conducted. To assess whether a specific risk behavior or its protective (nonrisk) behavioral analogue, composing a risk-nonrisk behavioral complex (eg, was sexually active and was sexually abstinent or used drugs and refrained from drugs), was stable over time, [Kappa] values were determined for the 10 risk-nonrisk behavioral complexes. Main Outcome Measures: Instrument assessing risk behaviors administered at baseline and every 6 months aurally and visually via talking computer. Results: The prevalence of sexual intercourse, cigarette smoking, alcohol consumption, and drug use increased notably over time. Drug use increased from a 6-month cumulative prevalence of 7% at baseline to 27% at the 24-month follow-up (P[is less than].001). Cumulatively over the 2-year study interval, 81% of youths had engaged in fighting, 58% had engaged in sexual intercourse, and from 33% to 40% had engaged in truancy, knife or bat carrying or both, alcohol consumption, drug use, and cigarette smoking. All of the risk-nonrisk behavioral complexes except weapon carrying were stable during the semiannual assessment intervals. Fighting ([Kappa]= 0.22, P[is less than].01), sexual intercourse ([Kappa] =0.33, P[is less than].001), alcohol consumption ([Kappa]=0.21, P[is less than].001), and unprotected sexual intercourse ([Kappa]=0.34, P[is less than].05) were stable for 2 years. Six risk-nonrisk behavioral complexes were stable for the 2-year interval among youths aged 13 through 15 years at baseline, while only 2 risk-nonrisk behavioral complexes were stable among younger youths. The intervention seemed to affect the stability of 4 risk behaviors: truancy, drug use, unprotected sexual intercourse, and, possibly, fighting. For unprotected sexual intercourse, this intervention effect seemed to be due to stabilization of nonparticipation in risky behavior. Intervention youths were less likely to adopt a risk behavior (de, engage in it for [is greater than or equal to]2 risk assessment periods) than control youths, but they were not less likely to experiment with a risk behavior. Conclusions: There is evidence that although the prevalence of risk behaviors does change with age, most risk-nonrisk behavioral complexes seem to be relatively stable over time and stability may increase with time. Risk reduction interventions seem to decrease risk adoption, stabilize nonrisk behaviors, and possibly destabilize risk behavior. Arch Pediatr Adolesc Med. 1997;151:398-406, Black low-income youths appear likely to experiment with risky behaviors, but may not adopt that behavior. Risk-reduction interventions may reduce the likelihood of adopting risky behaviors. Overall, 383 black 9- to 15-year olds responded to periodic surveys over a 2-year period. Risk behaviors, including sexual intercourse, cigarette smoking, alcohol and drug use, fighting, truancy, and carrying a knife or bat, remained stable among youths aged 13 to 15 at study onset but increased among younger youths. Youths counselled in how to avoid HIV infection were less likely to engage in truancy, drug use, unprotected sexual intercourse, and possibly fighting.

One promising avenue for augmenting the effect of interventions designed to reduce risk behaviors for acquisition of the human immunodeficiency virus (HIV) among adolescents is the use of peer influence through friendship groups. In this study, conducted among 76 groups of African American adolescents, the authors sought to determine whether the similarity of behaviors among group members persists over time and whether the similarity is enhanced through a risk-reduction intervention. Youth within groups were more similar compared to youth between groups with respect to sexual behaviors, expectations, and feelings at the baseline and through 18 months of follow-up. An HIV risk-reduction intervention that increased condom use also increased similarity of condom use among youth within intervention groups at 6 and 18 months postintervention. These data provide empiric support for the hypothesis that delivery of HIV-prevention efforts through groups of friends may be a useful intervention adjunct., Continued expansion of the AIDS epidemic reinforces the need to develop effective risk-reduction interventions, particularly those targeting potentially high-risk populations. Minority adolescents constitute one of these demographically important high-risk populations [...]