Order 187973: Public Health informatics informed approaches for monitoring or managing HIV in sex workers in Guyana (South America)

Sexually transmitted infections, drug use, and risky sex among female sex workers in Guyana

Introduction In Guyana, a steep increase in HIV sero- prevalence was observed among female com- mercial sex workers (CSWs) during the last decade; from no evidence of HIV infection in 1988, to 25% in 1993, and 46% in 1997.1–3

The dynamics of transmission as well as the distribution and determinants of high risk sex among them are poorly understood. The aim of this survey was to describe factors that may facilitate HIV transmission in this popula- tion.

Method Ethical clearance was obtained from the min- istry of health. In 1997, a survey was conducted among 73 street based and 51 brothel based female CSWs. Following verbal consent, a pretested questionnaire was ad- ministered by trained interviewers to collect data on sociodemographics, condom use, sexually transmitted diseases (STDs), and drug use (alcohol, “crack” cocaine, and mari- juana). Drug use was classified as “ever” ver- sus “never.” Condom use was dichotomised as consistent (always) or inconsistent (some- times or never). Logistic regression was used to determine independent predictors of high risk sex.

Results Their mean age was 30.6 years (SD 7.2 years) and their median time in sex work was 3.0 years. The street based and brothel based CSWs were similar with respect to age, mari- tal status, and time in sex work.

Sixty four per cent reported a history of at least one STD; 45% had genital discharge, 16% had vaginal ulcer, 25% had syphilis, and 16% had other STDs. In addition, 33 had salpingitis. Drug users were more likely to report STDs.

None of the women admitted injection drug use. Fifty one CSWs reported marijuana use

and 27 admitted using crack cocaine. All of the crack cocaine users, except one, reported they smoked marijuana. Forty one (34.5%) indi- cated that they were always under the influ- ence of alcohol while having sex with their last 10 clients. Brothel based CSWs were more likely to have been under the influence of alco- hol while having sex with their last 10 clients (59.2% v 17.1%; p<0.001) and less likely to use marijuana (30% v 49%; p=0.03) and crack cocaine (15.7% v 26%; p=0.169).

Forty four (36%) CSWs reported incon- sistent condom use with clients and 88% use condoms inconsistently with their stable partner. Seventy nine CSWs reported sex during menstruation. No significant diVer- ences were found between the brothel based and street based women with respect to sex during menstruation and frequency of con- dom use with clients. Factors that were significantly associated with inconsistent con- dom use with clients and sex during men- struation are shown in table 1. Crack cocaine use predicted inconsistent condom use while marijuana predicted sex during menstrua- tion.

Discussion The absence of injection drug use suggests that unsafe sexual intercourse may be the major risk behaviour for acquisition of HIV. The simultaneous presence of high levels of STDs, inconsistent condom use, and multi- drug use, should be a cause for concern, as they may interact to provide fertile conditions for sexual spread of HIV. In addition to their role in enhancing HIV transmission,4 STDs may also be an indicator of the extent of their potential exposure to HIV infection. Consist- ent with research that was conducted elsewhere,5 6 we found that drug users were more likely to engage in high risk sex. The

exact reason for this relation in this popula- tion is unclear. The low rate of condom with stable sex partners suggests that future stud- ies should investigate the role of these partners both as a source of HIV/STDs for the CSWs, as well as a potential bridge for HIV transmission into the community.

This study was funded by the National AIDS Program in Guyana and the Fogarty International Training Program, University of Miami.

NAVINDRA E PERSAUD Fogarty International Training Program, University of Miami and Ministry of Health, Guyana

WINSLOW I KLASKALA MARIANNA K BAUM

Fogarty International Training Program, University of Miami

ROBERT C DUNCAN Department of Epidemiology and Public Health, University of Miami

1 Carter KH, Harry BP, Juene M, et al. HIV risk perception, risk behavior and seroprevalence among female commercial sex workers in Georgetown, Guyana. Pan Am J Public Health 1997;1:451–9.

2 Persaud N, Klaskala K, Tiwari TSP, et al. Drug use and syphilis: cofactors for HIV transmis- sion among commercial sex workers in Guy- ana. West Indian Med J 1999;48:52–6.

3 UNAIDS. Epidemiological Fact Sheet on HIV/ AIDS and STDs. UNAIDS, 1998. Available from http://www.unaids.org.

4 Cohen MS. Sexually transmitted diseases en- hance HIV transmission: no longer a hypoth- esis. Lancet 1988;351(suppl 111):5–7.

5 Simeon DT, Bain BC, Wyatt GE, et al. Charac- teristics of Jamaicans who smoke marijuana before sex and their risk status for sexually transmitted diseases. West Indian Med J 1996; 45:9–13.

6 Messiah A, Bloch J, Blin P, et al. Alcohol or drug use and compliance with safer sex guidelines for STD/HIV infection. Results from the French national survey on sexual behavior (ACSF) among heterosexuals. Sex Transm Dis 1998;25:119–123.

Table 1 Factors associated with inconsistent condom use with clients and sex during menstruation—female sex workers in Guyana

Risk behaviour

Inconsistent condom use Sex during menstruation

Univariate eVect OR (95% CI)

Multivariate eVect* OR (95% CI)

Univariate eVect OR (95% CI)

Multivariate eVect* OR (95% CI)

(1) Cocaine use 4.4 (1.9, 10.5) 5.59 (2.04,15.3) 18.5 (3.8,87.0) 6.3 (0.7, 57.6) (2) Marijuana use 1.3 (0.6, 2.70) — 8.10 (3.1,20.9) 4.3 (1.4, 13.5) (3) Being married 7.4 (1.8, 30.8) 11.14 (1.92,64.7) 1.48 (0.3,7.70) — (4) Condom possession 0.3 (0.1, 0.90) 0.38 (0.11,1.32) 0.58 (0.2,1.50) — (5) Street walker 2.2 (1.0, 4.70) 2.10 (0.83,5.10) 1.63 (0.8,3.60) — (6) Secondary education 2.1 (1.01, 4.5) 2.30 (0.94,5.47) 1.96 (0.9,4.40) —

OR = odds ratio; CI = confidence interval. *Only variables that were significant on univariate analysis were placed in the multivariate model.

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risky sex among female sex workers in Guyana Sexually transmitted infections, drug use, and

Duncan Navindra E Persaud, Winslow I Klaskala, Marianna K Baum and Robert C

doi: 10.1136/sti.76.4.318 2000 76: 318 Sex Transm Infect

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(789)Syphilis (221)Health policy

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(2509)HIV / AIDS (3177)Drugs: infectious diseases

(1356)Reproductive medicine (761)Condoms

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