Evaluation of a targeted AIDS prevention intervention to increase condom use among prostitutes in Ghana

Abstract

Objective: To assess the short- and long-term impact of a 6-month pilot intervention program on condom use among prostitutes in Accra, Ghana.

Design: The 4-year prospective study follows-up cohorts enrolled in the intervention in 1987 and 1988, comparing condom use in 1991 with that among a comparison group not enrolled in the intervention.

Setting: The community-based intervention was initiated in Accra, Ghana in 1987.

Participants: Self-identified female prostitutes who volunteered participation.

Intervention: The educational intervention used local health workers to train and support selected prostitutes to be health educators and condom distributors to their peers.

Outcome measures: Self-reported condom use with clients.

Results: Reported condom use increased dramatically between 1987 and 1988 during the first 6 months of the intervention. In 1991, after 3 years of program relapse, 107 (43%) of the 248 women who had enrolled in 1987 or 1988 were still in prostitution and located for interview. Their level of condom use in 1991 was higher than pre-enrollment but similar to use among prostitutes never enrolled. Sixty-four per cent of those followed-up reported always using condoms with clients in 1991. These 'always users' were more likely to have maintained informal contact with project staff, know that HIV can be transmitted by healthy clients, and report that clients frequently initiate condom use.

Conclusions: Findings support the development of long-range educational strategies that recognize the career longevity of prostitutes, available channels for informal program diffusion, individual changes in condom use over time, and the role of clients in condom negotiation.

PIP: Findings of a prospective study of condom use among prostitutes in Ghana provided support for acquired immunodeficiency syndrome (AIDS) prevention educational interventions with this high risk populating and evidence of informal program diffusion. 382 self-identified prostitutes voluntarily entered the study in three waves (a pilot group of 72 recruited in June 1987, another 176 prostitutes who were admitted at their request in January 1988, and 106 who entered in September 1991). From this group, selected prostitutes were trained to educate their peers about AIDS risk factors through meetings and printed materials and to distribute free condoms. Self-reported condom use in 1991 was correlated with contact with these peer educators. During the 6-month pilot study, the proportion of prostitutes who always used condom increased from 6% at baseline to 71%. 48% of prostitutes entering the study in January 1988 were already always using condoms, suggesting a diffusion effect. In 1991, consistent condom use was reported by 56% of women from the pilot group available for follow-up and 66% of those interviewed from the 1988 wave; however, these rates were not appreciably higher than the 55% rate reported at baseline by the 1991 wave of recruits. (This convergence is assumed to reflect both suspension of the educational program in 1988-91 and increased social acceptance of condom use given the spread of AIDS.) Of the 107 women from the pilot and expanded groups available for interview in 1991, 24% identified peer outreach workers as their source of AIDS information. Women who had contact with staff were 2.63 times more likely than non-exposed women to report consistent condom use. The interaction model revealed that women who maintained contact with project staff were 3.17 times more likely to be consistent users, those who knew that healthy appearing men could transmit AIDS were 2.68 times more likely to fall into this use category, and prostitutes who had clients who initiated condom use more than half the time were 4.49 times more likely than other women to be consistent users, even when staff contact and AIDS knowledge were controlled. Given the career longevity of some prostitutes, sustained program activity is encouraged.