Female Sex Workers and STI/HIV in Ba Ria – Vung Tau Province, Vietnam: Transmission, Knowledge, Attitudes and Sexual Behaviors Author Nguyen, Tri Published 2016 Thesis Type Thesis (PhD Doctorate) School School of Medical Science DOI https://doi.org/10.25904/1912/68 Copyright Statement The author owns the copyright in this thesis, unless stated otherwise. Downloaded from http://hdl.handle.net/10072/367150 Griffith Research Online https://research-repository.griffith.edu.au FEMALE SEX WORKERS AND STI/HIV IN BA RIA – VUNG TAU PROVINCE, VIETNAM: TRANSMISSION, KNOWLEDGE, ATTITUDES AND SEXUAL BEHAVIORS TRI NGUYEN BHlthSc (PH), MPH School of Medicine Griffith Health Griffith University Submitted in fulfilment of the requirements of the degree of Doctor of Philosophy August, 2016 Abstract Female sex workers (FSWs) have been identified as one of the high-risk population groups for HIV and STI infections; they play a potential bridging role in the spread of the STI/HIV epidemic from specific high-risk populations to the general population. A cross-sectional study using mixed methods (quantitative research combined with qualitative research) was conducted to determine the prevalence of STI/HIV infections and assess the levels of STI/HIV-related knowledge, and attitudes towards STIs/HIV and sexual behaviours among FSWs in Ba Ria – Vung Tau, Vietnam. Quantitative research methods were used for an epidemiological survey to recruit 420 FSWs in two cities and six districts of Ba Ria – Vung Tau province, Vietnam. The survey explored the STI/HIV prevalence, socio-demographic characteristics and risk factors affecting FSWs. The recruited participants were interviewed face-to-face, using a structured questionnaire, and then tested for HIV, Syphilis, Gonorrhoea, and Chlamydia. Qualitative research methods using in-depth interviews with a subsample of 45 FSWs supplemented the quantitative research findings, especially in relation to different perspectives of risk behaviours among FSWs. Both FSWs who engaged clients directly (116) and indirectly (254), via brothels or other workplaces, participated in the study. About a quarter (25.4%) of the FSW sample were 24 years of age or under and 43.3% had minimal formal education. Almost half (48.1%) had been married or cohabited and 30.5% were living alone. The majority of the sample (63.1%) were unemployed before becoming FSWs. Two-fifths (40.2%) earned money solely by sex work. Regarding risky sexual behaviours, 52.6% had had their first sexual intercourse before the age of 18 years. 42.9% had provided sexual services to over 15 paying clients in the month prior to interview. Most (81.4%) practiced oral sex and a substantial proportion (17.6%) had had anal sex during this period. Most FSWs drank alcohol at least once a week. Only half of the FSW sample had ever heard of, or known about injecting drug usage, although nearly a quarter of them had used drugs. FSWs who engaged clients directly were significantly more likely to have sexual intercourse with clients who injected drugs than those who made contact through their workplace. 2 The prevalence of HIV among the FSW sample was 2.6%. The study showed that earning low income (less than AUD 200 per month), having had sex with injecting drug users (IDUs), and having been infected with any STI were significantly associated with HIV infection. The prevalence of Syphilis, Gonorrhoea, Chlamydia, and either Gonorrhoea or Chlamydia infections was 6.9%, 7.9%, 16.4%, and 21.4%, respectively. The prevalence of any STI (having at least one of these infections) was 27.1%. The multivariate logistic regression model found a significant association of any STI with “age group”, “education level”, “source of income”, and “monthly income”, “age of first sexual intercourse”, “working as FSWs”, “number of paying clients”, “had oral sex”, “had anal sex”, “had any IDU clients”, “feeling at risk for HIV infection”, “visited any STI clinic in the last 12 months”, and “received free or cheap condoms last month”. More than three quarters of the FSW sample (76.2%) had a high HIV knowledge, with correct answers for at least 7 out of 10 questions. However, only 23.3% of participants answered all items correctly. Over half (51.4%) of the FSWs felt themselves at risk of HIV infection. 86.0% of FSWs had heard about STI infections. Among them, 40.4% of the FSWs reported that they had suffered STI infections. Only 21.9 percent of FSWs had visited an STI clinic for a routine (non-infection related) check-up during the last 12 months. Nearly three quarters (72.4%) had received free condoms and over half (56.9%) had received information about safe sex and injecting drugs in the month prior to interview. Most (86%) FSWs knew of an STI/HIV testing clinic in Ba Ria – Vung Tau, and more than half (51%) had been tested for HIV/STIs. Among the FSWs who had been tested for STIs/HIV, 77.7% had been counselled before testing, 81.0% of FSWs had received the testing results and 96.0% of those who had received the results had been counselled after receiving testing results. 3 The qualitative exploratory study indicated that the main factors associated with a failure to use condoms among the FSWs included lack of skill in negotiating condom use; economic pressure; close relationships with clients; and clients' attitudes and perception of the risk. One of the most common reasons for FSWs’ alcohol consumption was that it was inevitable owing to the nature of their work environment. The main reason for using drugs among FSWs was that they were sad and unhappy with their work. Most of the participants knew or had heard that HIV/STIs could be transmitted through sexual intercourse. Most of the participants felt at risk of HIV infection because of their sex work. The results of this study clearly indicate a number of strong links between socio- demographic characteristics and risky sexual behaviours and STI/HIV infections. Therefore, there is an urgent need for existing STI/HIV intervention programs to be improved and strengthened in order to reduce the current level of STI/HIV infections. Comprehensive prevention, care, and treatment for STI/HIV infections should be developed and should be provided in settings that are easily accessed by, and comfortable for FSWs. 4 Key Words HIV/AIDS Sexually Transmitted Infections Female Sex Workers Transmission Risk Factors Sexual Behaviours Knowledge Attitudes Ba Ria - Vung Tau Vietnam 5 Statement of Originality This work has not previously been submitted for a degree or diploma in any university. To the best of my knowledge and belief, the thesis contains no material previously published or written by another person except where due reference is made in the thesis itself. Name of Student: Tri Nguyen _____________________________ Date: _________________ 6 Table of Contents Abstract ............................................................................................................................. 2 Key Words ........................................................................................................................ 5 Statement of Originality ................................................................................................... 6 Table of Contents.............................................................................................................. 7 List of Figures ................................................................................................................. 13 List of Tables .................................................................................................................. 14 Glossary of Terms and Acronyms .................................................................................. 16 Paper Published .............................................................................................................. 17 Acknowledgements ........................................................................................................ 18 CHAPTER 1: INTRODUCTION ............................................................................... 19 1.1. Background and Significance of the Research ........................................................ 19 1.2. Research Questions.................................................................................................. 22 1.3. Research Aim and Objectives.................................................................................. 22 1.3.1. Overall Aim ................................................................................................... 22 1.3.2. Specific objectives......................................................................................... 22 1.4. Structure of the study ............................................................................................... 23 CHAPTER 2: LITERATURE REVIEW ................................................................... 25 2.1. The global HIV/AIDS epidemic and the epidemic in Vietnam............................... 25 2.2. The HIV/AIDS epidemic among FSWs Globally and in Vietnam ......................... 28 2.2.1. The global HIV/AIDS epidemic among FSWs ............................................. 28 2.2.2. The HIV/AIDS epidemic among FSWs in Vietnam ..................................... 30 2.3. The global burden of STIs and STI epidemic in Vietnam ....................................... 31 2.4. The STI pandemic among FSWs worldwide and in Vietnam ................................. 33 2.4.1. The STIs among FSWs worldwide ..............................................................