HIV/STI prevention interventions for sex workers in different settings in Singapore: Impact, challenges and lessons learned from two decades of research
WORLD CONFERENCE ON STDs, STIs & HIV/AIDS
July 26-27, 2017 | Vancouver, Canada
Mee Lian Wong
National University of Singapore, Singapore
Keynote : Virology research J
Male patronage of female sex workers has been reported as the main mode of transmission of HIV and Sexually Transmitted Infections (STIs) in Asia. In Singapore, sex workers operate from diverse settings ranging from licensed brothels, to streets and entertainment establishments. A survey of licensed brothel-based sex workers in Singapore in 1992 found that 40% tested positive for STIs. Only 45% used condoms consistently with their clients because they could not persuade them to use condoms. I collaborated with the Department of STI Control (DSC), and we developed an intervention, using behavioral and work environment strategies to get health staff to motivate the sex workers to use condoms, develop their condom negotiation skills and mobilize support from brothel owners for condom use. Evaluation of the intervention, using a quasi-experimental design, showed a statistically significant increase in condom use with a corresponding decline in STIs. The intervention program was scaled up to all brothel-based sex workers in which they were required to attend STIs/HIV talks and skills development sessions on condom use and negotiation at the DSC Clinic. Program activities for brothel management included HIV/STI talks and mandatory display of posters on 100% condom use. Free condoms were given to all clients in the brothels. The program led to a sustained increase in condom use to more than 90% with a corresponding decline in STIs from 40 per 1000 person months to less than 1 per 1000 person-months among the sex workers. In recent years, globalization and wide income disparities across countries in Asia led to an influx of women from the region to work in entertainment establishments in Singapore. Our survey on entertainment establishments in Singapore in 2008 found that 70% of entertainment establishments provided sexual services. Almost all (>90%) of the female entertainment workers came from Asia and some came on short term social visit passes. Condom use with clients was low (<50%) among them. We faced more challenges in designing interventions for this group than for brothelbased workers because of their geographic mobility, illegal and hidden nature of their work, their lack of access to STI/ HIV screening and treatment, and the influence of alcohol on condom use. We collaborated with non-governmental organizations and developed outreach peer-led sessions on condom negotiation and alcohol consumption. Free condoms and STI screening were also provided. At 6-week follow-up, the intervention group was more likely than the control group to report consistent condom use with paid partners (75% vs. 42%; adjusted risk ratio [aRR] 1∙78; 95% CI: 1∙73 – 1∙84). There was also a corresponding significant decline in STI incidence (8∙2 % vs. 13.5%, p<0.05). Given the heterogeneity of sex work, we need to develop contextspecific and culturally appropriate multilevel interventions that address structural and behavioral barriers to condom use. It is crucial to address the social and structural influences on condom use among foreign sex workers in Singapore by working with relevant stakeholders and by using community empowerment strategies.
Mee-Lian Wong is Associate Professor of Public Health at the National University of Singapore - Saw Swee Hock School of Public Health. She received her MBBS and MPH from the University of Malaya and her Doctor of Medicine from the National University of Singapore. Her current research interests include health promotion, behavioral change and prevention of sexually-transmitted infections (STIs) and HIV among adolescents, heterosexual men and sex workers in Singapore and Cambodia. She has devoted 24 years to research in the development and evaluation of STI/HIV/AIDS programs and behavioral interventions for sex workers. She has published more than 100 papers on STI/ prevention and health promotion. Her research on HIV/STI prevention has earned her many awards, including (i) the Wilf Howe Memorial Prize 2008, Faculty of Occupational Health Physicians, United Kingdom, for outstanding intervention/research project on STI prevention among sex workers with demonstrable health benefits, (ii) Red Ribbon Award, Singapore 2014 for her invaluable research contributions in HIV prevention and control (iii) National Skin Centre (NSC) Distinguished Friend Award 2009, for significant contributions to the Department of STI Control, NSC in translational research in HIV/STI prevention and control (iv) SEAMEO-JASPER award, second best research on women and health for her research study, Women and Sexually transmitted Diseases: A Sustainable Intervention to Increase Condom Use and Reduce Gonorrhea among Sex Workers in Singapore, 1996 and (v) the Rockefeller Foundation’s (US) Reflections on Development Fellowship award, 1989 for her research on Women in Health and Community Development. She is also Visiting Consultant to the Department of STI Control, National Skin Center, Singapore. She has previously served as Assistant Dean of Preclinical Education at the Yong Loo School of Medicine, National University of Singapore; and Program Director of the National Preventive Medicine Residency Program, Singapore.