Overall, our study results indicate that even without being the direct target population of a concentrated HIV prevention intervention in La Romana, the majority of male partners of female sex workers reported using condoms consistently with their most recent regular female sex worker partner. The majority of men also perceived that at least some of their male social network contacts always used condoms with regular female sex worker partners and provided encouragement to use condoms. While resistance to condom use has traditionally been identified as a barrier to HIV prevention related to dominant norms of masculinity (UNAIDS, 2001
), our results suggest that in this setting, using condoms appears to have become acceptable and perhaps the expected behavior, even in the context of long-term sexual relationships between men and their regular female sex worker partners.
One possible explanation for the condom use rate is that longstanding, multi-level HIV prevention interventions in the commercial sex industry of the DR have created pro-condom norms that have diffused to both women and men (Kerrigan, Ellen et al., 2003a
; Kerrigan et al., 2006
). Additionally, the finding that the majority of male partners talked about condoms and had received encouragement to use condoms from their social networks suggests that in this culture small groups of men may have developed their own approaches to supporting each other to protect themselves from HIV without extensive external intervention. Given the small size and dense nature of networks in this context, it is likely that once new norms and behaviors are introduced, they are reinforced by the network. Friedman et al. (2004)
have referred to such organic forms of health promotion as “intravention”, in reference to a population of injection drug users in a New York City neighborhood with declining HIV prevalence. This foundation of “intravention” could provide a critical starting point for more targeted HIV prevention efforts with men.
While the majority of participants reported using condoms consistently with their most recent regular female sex worker partner, another important finding from this study is that a substantial portion of the men reported high numbers of sex partners in the last three months. Men who reported having 4 or more sex partners in the last three months were significantly less likely to report using condoms consistently with their most recent regular female sex worker partner. Consistent condom use was also significantly less likely among men with higher alcohol consumption frequency. These results highlight the continued vulnerability to HIV infection among men who are engaged in the commercial sex industry and their sex partners.
In examining the association between social network norms and consistent condom use, we found a significant positive association between perceived condom use among male social network contacts and reported consistent condom use by male partners. Our finding is consistent with previous studies documenting positive associations between descriptive network norms and sexual risk behaviors and intentions among heterosexual men and women and injection drug users (Buunk & Bakker, 1995
; Dedobbeleer, Morissette, & Rojas-Viger, 2005
; El-Bassel et al., 2006
; Latkin et al., 2003b
We also found that male partners who talked about condoms with all of their network contacts were significantly more likely to report using condoms consistently. Of note, we did not find that men who received encouragement to use condoms with female sex workers were more likely to report using condoms consistently. Encouragement to use condoms has been associated with condom use with female sex workers among male clients in Bali, and with other HIV protective behaviors among injection drug users (Davey-Rothwell & Latkin, 2007a
; El-Bassel et al., 2006
; Ford et al., 2002
; Latkin et al., 2003b
). One possible explanation for the lack of association between encouragement and consistent condom use is that injunctive norms may be less likely to exert an influence over a private behavior, such as condom use, because the threat of sanction for going against the group norm is weakened due to the fact that the behavior cannot be observed (Bendor, 2001
; Lapinski & Rimal, 2005
). Another consideration is that encouragement, which is one-way attempted influence, is resisted more than other indirect forms of influence such as talking and knowing the descriptive norms.
The third study aim was to identify social network characteristics associated with perceived condom use. We found that male partners who received encouragement from all of their social network contacts were significantly more likely to perceive that their male contacts used condoms consistently. Additionally, male partners whose male social network contacts all expressed dislike for condoms were significantly less likely to perceive that these contacts always used condoms. Encouragement to use condoms and expressing dislike for condoms reflect two different forms of interpersonal communication, which has been suggested as the prime source of information for the development of normative perceptions of private behaviors such as condom use (Hogg & Reid, 2006
; Lapinski & Rimal, 2005
). Therefore, rather than viewing descriptive norms as more influential on behavior than injunctive norms, we should perhaps view these two measures are complementary to one another. HIV prevention efforts with men can incorporate both types of norms through communication strategies that highlight direct descriptions of personal behavior as well as discussion of the normative expectations of condom use in this social context.
The finding that perceived condom use was significantly less likely in networks where everyone knew each other may reflect the premise from diffusion of innovation theory that dense networks may be slower to adopt innovations (Rogers, 2003
). One challenge in interpreting results regarding network density is that we only measured the existence but not the nature of ties (e.g. positive or negative, strong or weak). Given the fact that La Romana is a small city where most men reported having dense social networks, the question arises as to whether density reflects real closeness and availability of social support or if it is simply a reflection of people just knowing each other for a long time. While we did not find a direct association between network density and condom use, another area for future research is exploring how density may moderate the influence of norms on behavior.
The results of this study should be interpreted keeping in mind certain limitations. First, the cross-sectional nature of the survey does not allow us to identify causal relationships; men who use condoms consistently may recall more communications with their network and perceive more condom use within their networks. Second, the sample was not randomly selected and may not be generalizable to the broader population of male sex partners of female sex workers. For example, it is possible that our study included more social and extroverted men who were willing to talk about their sexual behavior. Finally, de Dspite our use of multiple measures, the reliance on self-reports of condom use could be biased, especially given the long history of condom promotion in the commercial sex industry in the DR. A previous study among the regular paying male partners of female sex workers in the capital city of Santo Domingo, however, reported a consistent condom use rate of 62% in a similar intervention context to the current study (Kerrigan, 2000
; Murray et al., 2006
Our results suggest that HIV prevention efforts that tap into existing social networks and communication patterns among male partners of female sex workers to promote pro-condom norms could be a viable way to reduce HIV vulnerability among individuals involved in the commercial sex industry and their sex partners. Social network interventions have achieved reductions in HIV risk behaviors among vulnerable male populations in Russia and Bulgaria (Amirkhanian et al., 2005
; Kelly et al., 2006
). The environment of commercial sex establishments in the DR with blaring music and high levels of alcohol consumption may challenge their appropriateness for venue-based interventions. Network-based HIV prevention efforts, however, could cross the border of the establishment and respond to the specific social reality of men, in particular those who resist pro-condom norms and other HIV protective behaviors, to promote HIV protective behaviors.