Understanding how contextual factors relate to condom use in FSWs living and working in Tijuana is vital to inform multilevel interventions to reduce their risk of acquiring HIV and other STIs, thereby improving their health and that of their partners and families. Using the Social Ecological Model as a framework, the present study took a multilevel approach to examine how individual, interpersonal, and institutional factors influence condom use in women at high risk for contracting HIV/STIs. Path analyses showed significant differences in how these factors differentially impacted condom use based on their primary place of work. For women who worked in bars, having more access to condoms was related to increased self efficacy and less unprotected sex. For street workers, economic incentives for unprotected sex, and lower levels of self-efficacy were related to more unprotected sex.
We also explored locations where street- and bar-based FSWs accessed condoms. Qualitative analysis noted the Prevemovihl
as a source of condoms for the street workers. This customized van, donated by the University of California San Diego, serves as a mobile HIV prevention clinic and provides HIV testing and prevention materials in Tijuana, especially in the Zona Roja [red light zone], where sex work is tolerated (Strathdee & Magis Rodriguez, 2008
). FSWs working on the streets accessed condoms from the prevemovihl
in higher numbers than did the bar workers, yet having access to condoms did not increase condom use self-efficacy or condom use. In contrast, women who worked in bars reported having greater access to condoms from their workplace. Having institutional support for condom use has been shown to increase condom use (Morisky et al., 2002
), and having access to condoms might be a reflection of this support. As hypothesized, for the women who worked in the bars, institutional factors (i.e., condom access) appeared to play a greater role in their condom use.
Among bar workers, having worked in the sex industry longer was related to greater numbers of unprotected sexual acts. The bar community values novelty and youth, and it is possible that as women get older and better known in the bar scene, they may feel the need to acquiesce to demands for unprotected sex in order to be competitive with younger, less experienced women. An alternative explanation might be that women who have a long career as a sex worker may feel demoralized and hopeless about their life circumstances and thus may be less careful during their encounters with clients. Depression has been shown to increase risky sexual behaviors in young women living in the United States (Mazzaro et al., 2006
For the women who worked on the street, length of time in the sex trade was not significantly related to unprotected sex. In their case, financial incentives were more important in determining condom use. Consistent with previous qualitative findings, we showed that being offered a higher financial incentive was related to more unprotected sex in the women working on the street (Bucardo et al., 2004
). Women who work on the street may lack institutional support and thus have to rely more heavily on interpersonal factors when making decisions related to condom use behaviors.
Research suggests that drug and alcohol use varies by work environment (Strathdee, Philbin, et al., 2008
), and the current study supports this. Substance use before sex reduces an individual's self-efficacy for condom use, making unprotected sex more likely. While type of substance use varied by work environment, both groups showed a negative relationship between substance use and self-efficacy. In response to the important role that drug use plays in the HIV/STI epidemics among FSWs in Tijuana, a new study is underway to test a behavioral intervention to reduce high risk sex occurring within the context of drug use.
This study has important limitations. Since the inclusion criteria for the larger study required unprotected sex with clients in the past month, the data reflect baseline measurements of women who were all practicing high-risk behaviors. The current findings therefore do not necessarily reflect predictors of condom use in women who use condoms more consistently with their clients. Despite this, the present study helps describe risk behaviors in women at a very high risk for acquiring HIV/STIs. When working to prevent the spread of HIV/AIDS in developing countries the issue of resource allocation is crucial. Findings from the present study can help tailor prevention efforts to FSWs based on location of sex work possibly increasing the cost-effectiveness of these efforts. Future studies should examine how the variables included in the present study (e.g. substance use, self-efficacy, access to condoms) interact to explain condom use in FSWs who do use condoms more consistently.
The consistent finding that bar and street workers differ on condom use, drug use, and the factors associated with these behaviors lends credence to the inclusion of structural and environmental targets when developing interventions for this population. The combination of more clients, less condom use, and higher drug use confirms that street-based FSWs are among the highest subgroup at risk of contracting HIV/STIs in Tijuana. For these women, client focused prevention efforts that increase safe sex negotiation skills may be more effective, but attention should also be paid to their non-paying partners as well. Poverty and drug use are also important motivating factors for unprotected sex in these women, therefore providing drug treatment, monetary incentives for condom use (i.e. contingency management), or job training opportunities may be novel prevention approaches for this group of women. For the women who work in bars, prevention efforts should focus on institutional incentives for promoting condom use, as well as individual level factors such as alcohol use and improving self efficacy for condom use. For both groups of women, our findings support the need for a multifaceted approach to HIV prevention that addresses both individual and environmental determinants of condom use, including poverty, drug and alcohol use, and location of sex work.