The Bali STD/AIDS study - Evaluation of an intervention for sex workers

Background: Prostitution has been an important factor in the spread of HIV infection in Asia. Interventions need to be developed to reduce the risk of transmission of sexually transmitted infections in this area. Goals: To educate female sex workers about sexually transmitted infections and assess the impact of the educational intervention. Study Design: Brothel areas in Denpasar, Bali, Indonesia, were divided into areas of high and low program (interventional) effort. The intervention included educational sessions for sex workers, treatment of sex workers for sexually transmitted disease (STD), condom distribution, and printed information for clients of the sex workers. A high-effort area was one in which a more intensive educational intervention occurred. A clinic was available for STD treatment in both areas. Behavioral surveys and STD testing were used to evaluate the programs. Six hundred female sex workers participated in behavioral surveys and STD examinations every 6 months for four rounds of data collection. Each round, about half of the women were new to the study. A total of 1586 women participated in at least one evaluation round. Changes were evaluated in AIDS knowledge, STD knowledge, and condom use, as well as in the prevalence of Neisseria gonorrhoeae, Chlamydia trachomatis, syphilis, and Trichomonas vaginalis. Testing for HIV was conducted anonymously. Results: Improvements were noted in the knowledge of sex workers about AIDS and STDs and in the reduction of some bacterial STDs. Women who remained in the study area for more than one round had increased knowledge of HIV infection/STDs and condom use and had reduced levels of syphilis, gonorrhea, and trichomonas infection (P < 0.01). The additional education received by women in the high-effort program area was associated with a reduction in the prevalence of syphilis. Prevalence of HIV remained low throughout the study. The high level of turnover of female sex workers contributed to the maintenance of significant levels of STDs in this population. Conclusions: Developers of HIV/STD prevention programs for sex workers need to consider the mobility of the sex worker population. Interventions combining behavioral and medical approaches can contribute to prevention of these diseases.