The number of study participants was 503 in 2000 and 506 in 2005. Comparing the population in 2000 and 2005, relatively small differences were seen in age and income (Table ). Larger changes had occurred in marital status, proportion of women in full-time sex work and workplace (from homes and guest-houses in 2000 to mainly bars and nightclubs in 2005). While the proportion of single women remained unchanged, in 2000 a substantial proportion (39.4%) were married or cohabiting, compared with only 2.5% in 2005. Sex work had changed from a predominately part-time to full-time activity; women with an alternative source of income decreased from 67.0% to 37.7% (P < 0.001). Most women in 2005 reported usually receiving payment for sex with cash (86.6%; 438/506), with the remainder receiving a combination of cash and gifts, clothing or food. In both time periods, about 90% of FSW had one or more children.
Participant's socio-demographic and socio-economic characteristics
In the 2005 survey, 28.7% (145/506) reported having attended peer-mediated interventions at least once. In the past six months, 78.6% (114/145) of these women had attended peer-education sessions, a median of four times (IQR 2–7). Eighty four percent of FSW who attended peer education had one-on-one sessions with peer educators (122/145). In a multiple-response question, women reported having participated in peer-mediated drama (43%; 62/145), role plays (41%; 59/145), picture code (32%; 47/145) and video sessions (3%; 4/145). About half (55%; 80/145) the women who received peer interventions reported that a peer educator had referred them to HIV testing.
Population-level effects, comparing female sex workers in 2000 and 2005
With more women reliant solely on sex work for their income in 2005, the mean number of sexual partners increased from 2.8 to 4.9 per week (P < 0.001). Merely 7.0% of women had four or more one-time clients per week in 2000; this increased to 33.2% in 2005 (OR = 6.6, 95%CI = 4.4–10.2; P < 0.001; Table ). These changes were accompanied by marked increase in condom use with clients, in last sex act (47.3% versus 85.8%; P < 0.001) as well as in consistent use, from 28.8% to 70.4% (OR = 5.9, 95%CI = 4.4–7.8; P < 0.001). No improvements were achieved with emotional partners, where still 80% of women did not use condoms consistently.
Sexual behavior and reproductive tract infections among female sex workers in 2000 and 2005, and a comparison between those in 2005 who had or had not received peer-mediated interventions
Sex worker empowerment
Among women reporting to have used a condom during last sex with a paying client, approximately 90% in both surveys mentioned this was their idea, and around 70% provided the condom themselves. The proportion of women who mentioned there is an advantage to knowing once HIV status was higher in 2005 (94.4% versus 78.3%; P < 0.001). An increase was also seen in the proportion of women who had ever refused one or more clients unwilling to use condoms from 41.4% to 77.7% (OR = 4.9, 95%CI = 3.7–6.6; P < 0.001). Still, of the 150 women in 2005 who reported inconsistent condom use with clients, 93 (62.0%) cited 'client refusal' as the reason for inconsistent use.
Reduced transmission efficiency
Being aware of HIV status increased markedly from 5.2% in 2000 to 40.2% in 2005. Syphilis prevalence remained unchanged, though increases had occurred in history of genital ulcer disease or abnormal vaginal discharge.
Individual-level effects, comparing those who had or had not received peer-mediated interventions
Those who had received peer-mediated interventions (peers) had a similar age, marital status, education and income to women who had never received peer interventions (non peers) (data not shown). However, compared with non-peers, peers were more likely to be muslim (42.8% versus 28.3%; P = 0.019) and to work from home (24.8% versus 12.5%; P = 0.002).
Individuals exposed to peer education had more consistent condom use with clients (86.2% versus 64.0%; P < 0.001; Table ). After adjusting for age, marital status, place of work and education, peers were 2.3 times more likely to suggest condom use (95%CI = 1.0–5.5; P = 0.05) and 1.7 times more likely to refuse clients unwilling to use condoms (95%CI = 1.0–2.8; P = 0.04). Peers had higher levels of knowledge on HIV and STI than non-peers. Specifically, 79.3% (115/145) of peers compared with 61.2% (221/361) of non-peers knew ≥ 2 symptoms of STI in women, 46.9% (68/145) of peers cited ≥ 2 ways to prevent STI, compared with 23.8% (86/361) of non-peers. These differences were statistically significant (P < 0.001).
When comparing STI in peers with non-peers, no significant differences were noted, but all differences were in the same direction. Curable STI (infection with syphilis, gonorrhea or trichomoniasis) were detected in 18.3% (26/142) of FSW who had received peer-mediated interventions, compared with 24.4% (85/348) in those unexposed (P = 0.14).
Effects of number of peer-education sessions attended
Women who had attended four or more peer education sessions in the past six months reported less sexual partners and higher levels of protected sex than women who attended fewer sessions (Table ). These women had a lower prevalence of all STI (including HIV), but these differences were not statistically significant. Prevalence of curable STI among those attending only one to three peer education session was 22% (16/73), compared with 14% (10/69) in those attending more sessions (P = 0.25). Similar findings were noted when number of peer session attended was analyzed as a continuous variable (data not shown).
Effects of number of peer education sessions attended on sexual behavior and reproductive tract infections
When comparing HIV prevalence in 2000 and 2005, a non-significant increase was noted: 30.6% (151/493) versus 33.3% (166/498; P = 0.36). No difference was seen among younger women 15–19 years (15%, 4/27 versus 15%, 4/26; P = 0.95). HIV infection increased with age to a peak in women 25–29 years in 2000 and then declined with increasing age. In 2005, this peak occurred in older women, 35–39 years. Though not significantly different, HIV prevalence was lower in peers (29.6%; 42/142) compared with non-peers (34.8%; 124/356; P = 0.26). HIV prevalence was 25% (17/69) in FSW who attended four or more peer-education session, compared with 34% (25/73) in those attending one to three sessions (P = 0.21).