In this paper, we present data from observational studies of male clients of FSWs in Cotonou and other main cities in Benin. IBBS data from studies with clients carried out in 1998 (Cotonou only), 2002 and 2005 (all towns) indicate that over the period of implementation of the intervention in both sites, condom use rates with both FSWs and other (non‐FSW) casual female partners increased significantly over time, while rates of gonorrhoea decreased significantly.
While recognising the limitations of observational data in providing conclusive evidence of the effectiveness of HIV/STI preventive interventions, the internal consistency of the data (in terms of different indicators giving the same trends), as well as their consistency over time and in different sites, lends weight to the hypothesis that the interventions themselves, as opposed to other factors, have contributed to positive changes in indicators of behavioural risk and STI prevalence among clients. In particular, the later time of implementation of the project outside Cotonou allows the examination of the data as if resulting from a natural experiment. While reported condom use rates with FSWs were similar in Cotonou to those outside Cotonou around the time of implementation of the interventions (1998 and 2002, respectively), by 2005 rates had risen to very similar levels in both sites. This is also the case for decreases in gonorrhoea prevalence.
A more rapid increase in condom use rates with FSW, and corresponding decrease in gonorrhoea prevalence, occurred outside Cotonou. Also, the rate of increase in condom use with FSWs was significantly higher in Cotonou from 2002 to 2005 than from 1998 to 2002. One possible explanation for these findings is that scaling up of the intervention to a high proportion of clients and FSWs in Benin accelerated changes in behaviour and STI prevalence. FSWs, and to some extent clients, are highly mobile populations, and thus expanding the intervention to most large cities in Benin may have avoided re‐seeding infections from one city to another; as well as affecting condom use rates. It is also possible that the simultaneous implementation of interventions targeted towards both FSWs and their clients may have accelerated the rate of decline in STI prevalence and the increase in condom use rates in commercial sex encounters.
Given the long incubation period of AIDS, a stable HIV prevalence may well indicate a decrease in incidence over time. However, the stable chlamydia prevalence observed, compared with the decrease in gonorrhoea prevalence, may indicate a phase‐specific effect of the intervention. In contrast to gonorrhoea, the differential between chlamydia prevalence in high‐risk groups and the general population is small in Cotonou.1,3,4
Chlamydia may therefore be in a more endemic phase than gonorrhoea, where transmission among the low‐risk population may account for persistence, even in the presence of reduced transmission among high‐risk groups.
In addition to its observational nature, there are a number of potential limitations to this study. First, activities implemented by the National AIDS Programme, especially global AIDS awareness campaigns, may have partly contributed to the increase in condom use and subsequent decrease in STIs, although they cannot easily account for the differences observed between Cotonou and the other majn cities in Benin in 2002. Second, self‐reporting of condom use is prone to social desirability bias; it is however recognised that clients report lower condom use than FSWs.6
In a study carried out in Cotonou in parallel to the 2002 IBBS, we observed that, while FSWs and their clients usually gave the same answer about condom use in the sexual intercourse they had just had, most of the discrepancies were related to lower reported condom use by the clients.18
Finally, 25–40% (depending on the surveys) of the clients contacted did not participate, which could result in selection bias. However, participation rates were similar to those reported in other studies on clients of FSWs7,9
and to those reported in the National Survey of Sexual Attitudes and Lifestyle carried out in the UK from 1999 to 2001.19,20
In addition, non‐participation was in part due to a lack of sufficient staff to ensure that all clients approached would have their urine sample collected and their interview administered without waiting, particularly in very busy prostitution venues.
It is not possible to separate out the extent to which the decreased STI rates or increased condom use rates with FSWs among the clients were due to the interventions directed towards the FSWs themselves21
or to the male clients. Studies in other settings have shown declines in client STI prevalence as a result of interventions directed towards FSWs.22,23
However, in this study, the findings from the pilot intervention concerning the ability of the clients themselves to correctly put a condom on a wooden penis, and the proportions of clients who had put the condom on themselves (as opposed to the FSW putting it on), do suggest at least some direct effects on the clients' behaviour. The reported increases in condom use rates by clients with casual non‐FSW partners also suggest that behavioural change occurred among the clients themselves. It is also possible that focusing on “both sides of the equation” is a more effective way of achieving behavioural change than focusing only on FSWs. Given the prevailing nature of gender power relations, particularly in developing countries, as well as the high mobility and turnover rates characteristic of FSW populations in many settings, if both male clients and FSWs can be reached by preventive interventions, the likelihood that sustainable behavioural change during commercial sex will be achieved may be considerably enhanced.
- At least in some areas of sub‐Saharan Africa, it is possible to reach male clients of female sex workers (FSWs) for HIV/STI preventive and clinical services
- Preventive interventions directed towards both FSWs and their clients may be synergistic in achieving a significant effect on sexual risk behaviour, as well as on STI rates (particularly gonorrhoea), in these populations
- Scaling up coverage to the country level may enhance the impact of interventions targeted towards FSWs and clients in any particular setting covered