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Condom use within non-commercial partnerships of female sex workers in southern India Deering, Kathleen N; Bhattacharjee, Paranita; Bradley, Janet; Moses, Stephen S; Shannon, Kate; Shaw, Souradet Y; Washington, Reynold; Lowndes, Catherine M; Boily, Marie-Claude; Ramesh, Banadakoppa M; Rajaram, S; Gurav, Kaveri; Alary, Michel Dec 29, 2011

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REVIEW Open AccessCondom use within non-commercial partnershipsof female sex workers in southern IndiaKathleen N Deering1*, Paranita Bhattacharjee2, Janet Bradley3, Stephen S Moses4,5, Kate Shannon6,Souradet Y Shaw5, Reynold Washington2, Catherine M Lowndes7, Marie-Claude Boily8, Banadakoppa M Ramesh2,S Rajaram2, Kaveri Gurav2, Michel Alary3AbstractBackground: Although female sex workers (FSWs) report high levels of condom use with commercial sex clients,particularly after targeted HIV preventive interventions have been implemented, condom use is often low withnon-commercial partners. There is limited understanding regarding the factors that influence condom use withFSWs’ non-commercial partners, and of how programs can be designed to increase condom use with thesepartners. The main objectives of this study were therefore to describe FSWs’ self-reported non-commercial partners,along with interpersonal factors characterizing their non-commercial partnerships, and to examine the factorsassociated with consistent condom use (CCU) within non-commercial partnerships.Methods: This study used data collected from cross-sectional questionnaires administered to 988 FSWs in fourdistricts in Karnataka state in 2006-07. We used bivariate and multivariable logistic regression analysis to examinethe relationship between CCU (i.e., ‘always’ compared to ‘never’, ‘sometimes’ or ‘frequently’) with non-commercialpartners of FSWs (including the respondents’ husband or main cohabiting partner [if not married] and their mostrecent non-paying partner [who is neither a husband nor the main cohabiting partner, and with whom the FSWhad sex within the previous year]) and interpersonal factors describing these partnerships, as well as social andenvironmental factors. Weighting and survey methods were used to account for the cluster sampling design.Results: Overall, 511 (51.8%) FSWs reported having a husband or cohabiting partner and 247 (23.7%) reportedhaving a non-paying partner. CCU with these partners was low (22.6% and 40.3% respectively). In multivariableanalysis, the odds of CCU with FSWs’ husband or cohabiting partner were 1.8-fold higher for FSWs whose partnerknew she was a sex worker (adjusted odds ratio [AOR]: 1.84, 95% confidence intervals[CI]: 1.02-3.32) and almost 6-fold higher if the FSW was unmarried (AOR: 5.73, 95%CI: 2.79-11.76]. CCU with FSWs’ non-paying partner decreasedby 18% for each one-year increase in the duration of the relationship (AOR: 0.82, 95%CI: 0.68-0.97).Conclusions: This study revealed important patterns and interpersonal determinants of condom use within non-commercial partnerships of FSWs. Integrated structural and community-driven HIV/STI prevention programs thatfocus on gender and reduce sex work stigma should be investigated to increase condom use in non-commercialpartnerships.BackgroundInformation about the non-commercial partners offemale sex workers (FSWs) in the context of HIV andother sexually transmitted infection (STI) epidemiologyis limited. Of particular interest in HIV/STI preventionand care programming is the observation that, althoughcondom use within the commercial sex partnerships ofFSWs is frequently reported to be high, condom use ismuch lower within non-commercial partnerships [1-5].HIV preventive interventions targeted toward FSWshave typically focused on increasing FSWs’ condom usewith commercial clients, since the contribution of com-mercial sex partnerships of FSWs and clients to HIVepidemics is believed to be high in many settings [6-9].* Correspondence: kdeering@cfenet.ubc.ca1Division of AIDS, Department of Medicine, Faculty of Medicine, University ofBritish Columbia, Vancouver, CanadaFull list of author information is available at the end of the articleDeering et al. BMC Public Health 2011, 11(Suppl 6):S11http://www.biomedcentral.com/1471-2458/11/S6/S11© 2011 Deering et al; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.Indeed, as suggested in a systematic review of studies insub-Saharan Africa and Asia, HIV preventive interven-tions focusing on behaviour change are more effective atincreasing condom use within commercial compared tonon-commercial partnerships of FSWs [10]. The evi-dence for increased condom use with non-commercialpartners after interventions have been implemented isnot conclusive. Some studies show increases in condomuse [4,11], while others do not [12-14]. Limited researchhas been conducted to elucidate the reasons for low con-dom use within non-commercial partnerships of FSWsand how this can be addressed by HIV programming.Understanding condom use in non-commercial partner-ships is complex. The sex partners of FSWs are usuallycategorized as commercial/paying versus non-commercial/non-paying. Non-commercial partners can include hus-bands, boyfriends or lovers, as well “men who have freesex” (e.g., police or others who use power or force) [15].FSWs have varying degrees of emotional closeness, inti-macy or other involvement with these partners, whichmay influence condom use. Condoms may be used lessfrequently with non-commercial partners compared tocommercial clients in order to make a distinction betweenwork and pleasure [16,17]. Condoms may be preferred incommercial partnerships to create a barrier to intimacyand to gain a sense of control with clients [18]. Not usingcondoms in non-commercial partnerships can representpositive features of a relationship, such as increased close-ness and trust, and so condoms may be avoided to removea barrier to increased intimacy [18]. Conversely, the use ofcondoms may also be perceived as a symbol of infidelityand foster mistrust [16]. Fertility desires or the use ofother types of contraceptives, including female sterilizationmay impact whether or not condoms are used in non-commercial partnerships.Previous research among FSWs in our study setting ofsouthern India has found that exposure to a large-scaleHIV preventive intervention (the Avahan India AIDSInitiative [19]), while associated with increased condomuse with commercial clients, was not associated withincreased condom use with FSWs’ non-commercialpartners in the first few years of the intervention [20].The main goal of this study was therefore to explorecharacteristics of these non-commercial partnerships inmore detail to better understand the reasons for consis-tent condom use (CCU) with non-commercial partners.MethodsStudy design and samplingDuring 2006-07, in-depth cross-sectional quantitativeinterviews (Special Behavioural Surveys, SBS) were con-ducted with 988 FSWs in four districts (Bangalore, Bel-gaum, Bellary and Mysore) in Karnataka state, southernIndia. A probability sampling method was employed, usingtime-location cluster sampling with normalized weightscalculated to account for the complex sampling design.Sampling methods were similar to those reported byRamesh et al [21] for other studies carried out amongFSWs in southern India. The SBS collected informationon characteristics of two groups of FSWs’ non-commercialpartners: (1) their husband (if married) or main cohabitingpartner (if unmarried); and (2) their most recent non-pay-ing partner (who was neither a husband nor the maincohabiting partner described above). Only women whoreported having sex with their most recent non-payingpartner in the year preceding the conduction of the studywere included in (2). Of note, these are not mutuallyexclusive categories and there may be some overlap (i.e.,some women with a husband or main cohabiting partnermay have an additional non-paying partner). Some womenmay have a husband, but not necessarily be cohabitingwith him (information not available from the survey). TheSBS also collected information on social factors, sexualbehaviours and condom use with different non-commer-cial partners as well as commercial partners (i.e., occa-sional clients, who FSWs are not familiar with and whovisit FSWs once; and repeat or regular clients, who FSWsare familiar with and who visit FSWs more than once), aswell as on the working environment of FSWs and expo-sure to the ongoing HIV prevention program [19,22].Survey organization and methodsThe SBS was implemented by the CHARME-India pro-ject in collaboration with the Institute of PopulationHealth and Clinical Research, St John’s Medical College,Bangalore, the Centre hospitalier afflilié universitaire deQuébec, Québec, Canada and the University of Mani-toba, Winnipeg, Canada. The surveys were administeredthrough face-to-face interviews and were conductedanonymously, with no names or personal identifiersrecorded. A detailed and standardized consent processwas implemented for each respondent. The surveys andtheir protocols were approved by the Government ofIndia’s Health Ministry Screening Committee, therespective Canadian university ethics boards and StJohn’s Medical College, Bangalore.OutcomesCCU with each type of partner was derived from thesurvey question: “How often is a condom used whenyou have sex with <this partner>?” Women were consid-ered to use condoms consistently with each partner, ifthey answered ‘always’ compared to inconsistently,which was defined as ‘never’, ‘sometimes’ or ‘frequently’.Interpersonal, social and environmental factorsBased on previous literature we defined a priori a set ofinterpersonal factors in the survey specific to eachDeering et al. BMC Public Health 2011, 11(Suppl 6):S11http://www.biomedcentral.com/1471-2458/11/S6/S11Page 2 of 12partner that may influence CCU with non-commercialpartners [1,23]. Common across the two partner group-ings were the following variables: duration of the rela-tionship; number of times had sex with the partner in amonth; if the partner asks for anal sex; the partner’semployment status; if the partner knows the respondentis a sex worker; and if the respondent believes her part-ner has sexual relationships with other women. Forwomen with a husband or cohabiting partner, additionalfactors explored included: partner’s age; age differencebetween the husband or cohabiting partner and therespondent; and the number of months stayed togetherin the past year. For women with a non-paying partner,additional factors included: if the respondent ever staysor lives with the partner (not necessarily in a formalcohabiting relationship); if the partner provides therespondent with economic support; if the respondentprovides the partner with economic support; if therespondent is normally under the influence of alcoholduring sex with the partner; and if the partner is nor-mally under the influence of alcohol during sex with therespondent.For each model of CCU, we also examined the impactof social and environmental factors related to therespondent. Social factors included age, marital status(married versus unmarried, including those FSWs of theDevadasi tradition, a form of temple-based sex workwhereby women are dedicated through marriage to godsor goddesses [24-26]), age at first sex, age at first sexwork and duration of sex work; environmental factorsincluded district of residence, education (literacy), hav-ing sex work as sole income, and working environment,which was represented by type of solicitation (indepen-dent or through a middleman/pimp) as well as the placeof solicitation of clients.Statistical analysisStatistical analysis was conducted using Stata Version10.1 [27]. Continuous variables were categorized basedon previous literature if they did not have a linear rela-tionship with the logit of the binary outcomes [28]. Inbivariate analyses, c2 tests were used to assess associa-tions between social and environmental factors, andwhether or not FSWs had each type of non-commercialpartner, as well as associations between interpersonal,social and environmental factors and CCU. Multivari-able logistic regression models were developed withCCU as the outcome, for each of the two types of part-ners. Inclusion into multivariable models for all poten-tial covariates were based on significance at the P<0.10-level from bivariate analysis. Sampling weights were uti-lized in multiple regression models to account for thecomplex sampling design, using survey methods. Multi-collinearity in multivariable models was assessed usingthe variance inflation factor (VIF) and tolerance statis-tics, corrected for the survey methods employed [29].Adjusted odds ratios (AORs) and 95% confidence inter-vals (95% CIs) were reported for multivariable logisticregression. All P-values reported are two-sided.ResultsSample characteristicsOf the total sample of 988 FSWs, 208, 198, 369 and 213women were recruited in Belgaum, Bellary, Bangaloreand Mysore, respectively. The median age was 30 years(interquartile range: 25-35 years) and the median dura-tion of sex work was 5 years (interquartile range: 2-10years). Of the whole sample, 90.9% of women reportedusing some form of contraception for family planning(primarily female sterilization or condom use). Overall,511/985 (51.8%) FSWs reported having a husband orcohabiting partner (with three non-response) and 247/987 (23.7%, with one non-response) reported having anon-paying partner. Of these samples, 506 FSWs hadvalid responses to condom use with the husband orcohabiting partner and 101 (22.6%) reported CCU withtheir partner; 247 FSWs had valid responses to condomuse with the most recent non-paying partner and 92(40.3%) reported CCU with their partner. Figure 1describes the sex partnering patterns of FSWs, accordingto the types of partners reported by FSWs. All FSWsreported having occasional clients. The highest propor-tion of FSWs had both a husband or cohabiting partnerand repeat clients (23.5%), followed by FSWs with onlyrepeat clients (22.2%) and only a husband or cohabitingpartner (16.7%) (Figure 1). The lowest proportion of thepopulation had a husband or cohabiting partner and anon-paying partner (5.0%). Overall, 6.3% of FSWs hadall four different types of partners and 11.3% of FSWsonly had occasional clients (Figure 1).Additional file 1 presents characteristics of FSWsaccording to whether or not they reported having a hus-band or cohabiting partner, or a recent non-paying part-ner with whom they had sex within the last year. OfFSWs who reporting having a husband or cohabitingpartner 52.8% were currently married and 47.2% wereunmarried (i.e., cohabiting). FSWs with and without ahusband or cohabiting partner differed significantly interms of district of residence. Compared to FSWs with-out a husband or cohabiting partner, FSWs with thesepartners were significantly more likely to be older whenthey initiated sex work, be literate, report sex work astheir sole income, and have higher CCU with their mostrecent non-paying partner, with all repeat clients and alloccasional clients. FSWs with and without a non-payingpartner differed significantly in terms of district of resi-dence. Compared to FSWs who did not have a non-pay-ing partner, FSWs with a non-paying partner wereDeering et al. BMC Public Health 2011, 11(Suppl 6):S11http://www.biomedcentral.com/1471-2458/11/S6/S11Page 3 of 12significantly more likely to be younger at first sex, olderwhen they initiated sex work, were less likely to work inpublic places and more likely to work at home, and hadlower CCU with occasional clients.Interpersonal characteristics of non-commercial partnersand partnershipsTable 1 presents descriptive characteristics of the hus-band or cohabiting partner of FSWs, and of their mostrecent non-paying partner, as well as characteristics ofthese partnerships. The majority of the husbands orcohabiting partners were 35 years or older (mean=36.6years old). Overall, most of the husbands or cohabitingpartners were older than the FSW, with less than 10%being the same age or younger (mean=5.9 years differ-ence). FSWs reported that their relationship with theirhusband or cohabiting partner had been ongoing formuch longer than their relationship with their non-pay-ing partner. In the last year, approximately half of FSWshad stayed in the same place as their husband orcohabiting partner for 9 months or more (mean=7.3months). Overall, about a quarter of FSWs reported thatthey had at some time lived or stayed with their non-paying partner. The vast majority of husbands or coha-biting partners and non-paying partners were employed.FSWs reported a higher number of sex acts per monthwith their husband or cohabiting partner (mean=7.1 sexacts) than they did their non-paying partner (mean=4.6sex acts). FSWs reported that a higher proportion oftheir non-paying partners (about 2-fold more) everasked for anal sex compared with their husbands orcohabiting partners. FSWs reported that a higher pro-portion of their non-paying partners knew they were sexworkers compared to their husband or cohabiting part-ner (about 1.7-fold more). The majority of FSWsreported that their non-paying partner provided themwith some economic support, while the minority ofFSWs provided their non-paying partner with economicsupport. About half of the FSWs reported that theywere usually under the influence of alcohol duringFigure 1 Sexual partnering patterns of female sex workers across four districts in Karnataka state, southern India, including womenwith a husband or cohabiting partner, (at least one) non-paying partner who is neither a husband nor the main cohabiting partner and repeatclients, and who have multiple types of partners. All female sex workers have occasional clients.Deering et al. BMC Public Health 2011, 11(Suppl 6):S11http://www.biomedcentral.com/1471-2458/11/S6/S11Page 4 of 12sexual intercourse with their non-paying partner whileslightly more than half reported that their non-payingpartner was usually under the influence of alcohol dur-ing sexual intercourse.Sexual partnering patterns of non-commercial partnersFSWs reported that almost half of their husbands orcohabiting partners (41.1%) had sex partnerships withother women, while this was the case for the majority oftheir most recent non-paying partners (70.2%) (Table 1).Respondents whose partner had another sex partnerreported that the other partners of their husband orcohabiting partner or non-paying partner could include,respectively, a wife within town (46.6% and 59.8%), a wifeoutside town (24.9% and 28.9%), a sex worker withintown (16.6% and 7.2%), a sex worker outside town (8.2%and 8.8%), another type of female partner within town(6.8% and 5.9%) or another type of female partner outsidetown (6.7% and 3.9%) (results not shown).CCU with non-commercial partnersTable 2 presents results from bivariate analysis examin-ing the relationship between interpersonal, social andenvironmental factors and CCU, with the two types ofnon-commercial partners. Compared to FSWs whoreported using condoms inconsistently with their hus-band or cohabiting partner, FSWs who reported usingcondoms consistently were closer in age to their hus-band or cohabiting partner, with a shorter relationshipduration. A significantly higher proportion also had ahusband or cohabiting partner who asked for anal sexand who knew they were sex workers. They were alsosignificantly more likely to be unmarried, literate andolder at their age of first sex. They also differed signifi-cantly in terms of district of residence and place of soli-citation. Compared to FSWs who reported usingcondoms inconsistently with their non-paying partner,FSWs who reported using condoms consistently had asignificantly shorter relationship duration, and weremore likely to report at some time living or staying withtheir non-paying partner. FSWs with CCU also differedsignificantly in terms of district of residence and placeof solicitation from FSWs who used condomsinconsistently.Table 3 presents results from the multivariable regres-sion modelling analysis. FSWs were 1.8-fold as likely toTable 1 Characteristics of non-commercial partners and partnerships of female sex workers in four districts inKarnataka state1,2Husband or cohabiting partnerN=511Most recent non-paying partnerN=247Proportion (N)/ median (mean)INTERPERSONALPartner’s age (years)<3535 +38.1% (180)61.9% (326)n/aAge differenceFSW older or same ageMale partner older (<5 years)Male partner older (5-9 years)Male partner older (10+ years)9.7% (49)27.5% (116)37.0% (208)25.8% (133)n/aDuration of relationship (years) 9 (9.9) 2 (3.8)Number of months stay together in last year (months)<99+47.9% (215)57.1% (286)n/aEver have stayed or lived with partner n/a 27.6% (34)Partner is employed 94.8 (481) 99.2% (239)Number of times have sex with partner in a month (times) 5 (7.1) 4 (4.5)Partner asks for anal sex 16.8 (76) 33.5% (68)Partner has sexual relationships with other women 41.1 (185) 70.2% (166)Partner knows respondent is a sex worker 30.8 (147) 49.6% (114)Partner provides respondent with economic support n/a 78.3% (185)Respondent provides partner with economic support n/a 22.3% (59)Respondent normally under influence of alcohol during sex w/ partner n/a 49.6% (119)Partner normally under influence of alcohol during sex w/ respondent n/a 63.9% (155)1n/a: question was not available for this type of non-commercial partner2The denominators of each measure may not add up to the total samples due to missing dataDeering et al. BMC Public Health 2011, 11(Suppl 6):S11http://www.biomedcentral.com/1471-2458/11/S6/S11Page 5 of 12Table 2 Bivariate relationships between interpersonal, social and environmental factors, and condom use1.Husband or cohabiting partner Most recent non-paying partnerConsistentcondom useN=101Inconsistentcondom useN=405P Consistentcondom useN=92Inconsistentcondom useN=155PProportion (N)/ Median (Mean) Proportion (N)/ Median (Mean)InterpersonalPartner’s age (years)<3535 +39.0% (35)61.0% (66)37.6% (144)62.4% (260)0.865 n/aAge differenceFSW older or same ageMale partner older (<5 years)Male partner older (5-9 years)Male partner older (10+ years)6.7% (17)27.3% (23)38.9% (36)27.1% (25)20.1% (32)27.6% (92)30.9% (172)21.3% (108)0.002 n/aDuration of relationship (years)5 (6.9)10 (10.7) <0.001 2 (2.3) 3 (4.6) <0.001Number of months stay together in last year(months)<99+57.4% (52)52.5% (48)45.1% (163)54.9% (238)0.103 n/aEver have stayed or lived with partner n/a 27.5% (18) 10.9% (16) 0.010Partner is employed 96.9% (4) 94.1% (22) 0.276 100% (0) 99.0% (1) –Number of times have sex with partner in a month(times)4 (6.0) 5 (7.4) 0.194 3 (4.1) 4 (4.7) 0.353Partner asks for anal sex 26.1% (21) 14.1% (55) 0.017 41.2% (27) 28.3% (41) 0.122Partner has sexual relationships with other women 39.1% (39) 41.6% (146) 0.755 64.1% (55) 74.5% (114) 0.163Partner knows respondent is a sex worker 41.5% (42) 27.8% (105) 0.017 46.7% (41) 51.5% (73) 0.553Partner provides respondent with economic support n/a 79.9% (71) 77.2% (114) 0.656Respondent provides partner with economic support n/a 23.7% (22) 21.3% (37) 0.719Respondent normally under influence of alcoholduring sex with partnern/a 41.1% (37) 55.3% (82) 0.103Partner normally under influence of alcohol duringsex with respondentn/a 61.5% (54) 65.5% (101) 0.587SocialAge<2525 +15.6% (11)84.4% (90)20.1% (73)79.9% (332)0.451 19.2% (20)80.8% (72)24.8% (37)75.2% (118)0.344Marital statusCurrently marriedUnmarried19.5% (29)80.5% (72)62.3% (269)37.7% (136)<0.001 26.2% (28)73.8% (64)32.9% (50)67.1% (105)0.369Age at first sex (years)<1515+22.2% (26)77.8% (75)31.9% (133)68.1% (272)0.098 34.4% (27)65.6% (65)48.1% (67)51.9% (88)0.107Age at first sex work (years)<2020+24.5% (21)75.5% (80)23.1% (78)76.9% (327)0.809 31.2% (27)68.8% (65)40.3% (56)59.7% (99)0.268Duration of sex work (years)<55+39.1% (39)60.9% (62)45.0% (196)55.0% (209)0.325 39.3% (40)60.7% (52)41.1% (70)58.9% (85)0.827EnvironmentalDistrictBelgaumBellaryBangaloreMysore2.9% (3)13.9% (19)9.4% (18)73.8% (61)16.1% (51)23.4% (90)32.7% (173)27.8% (91)<0.001 8.8% (9)27.9% (24)32.0% (35)31.3% (24)51.6% (63)18.5% (31)29.5% (60)0.5% (1)<0.001Literate 63.2% (64) 44.7% (194) 0.004 30.5% (31) 22.9% (44) 0.229Sex work sole income 37.0% (34) 30.1% (108) 0.217 50.5% (49) 63.4% (99) 0.120Independent solicitation 67.7% (71) 77.2% (307) 0.230 79.4% (75) 76.5% (121) 0.714Deering et al. BMC Public Health 2011, 11(Suppl 6):S11http://www.biomedcentral.com/1471-2458/11/S6/S11Page 6 of 12use condoms consistently with their husband or cohabit-ing partner if the partner knew they were sex workers(AOR: 1.84, 95%CIs: 1.02-3.32). FSWs who were unmar-ried (i.e., had a main cohabiting partner rather than ahusband or cohabiting partner) were significantly morelikely to report using condoms consistently (AOR: 5.73[2.79-11.76]). CCU with the non-paying partner was sig-nificantly associated with a shorter duration of therelationship (AOR: 0.82, 95% CIs: 0.68-0.97). CCU withboth types of non-commercial partners was also signifi-cantly associated with district in multivariable analysis.DiscussionThe findings from this study have helped to elucidatehow interpersonal characteristics of partnerships caninfluence condom use with non-commercial partners ofTable 2 Bivariate relationships between interpersonal, social and environmental factors, and condom use1. (Continued)Place of solicitationHomeBrothelPublic places17.4% (19)10.9% (9)71.7% (73)26.0% (130)7.4% (45)66.6% (230)0.004 26.1% (25)7.6% (10)66.4% (57)29.4% (52)19.7% (33)50.9% (70)0.053Bivariate relationships between interpersonal, social and environmental factors, and condom use with non-commercial partners of female sex workers in fourdistricts in Karnataka state11n/a: question was not available for this type of non-commercial partnerTable 3 Multivariable (adjusted) odds ratios (AOR) and 95% confidence intervals (95%CIs)1,2,3Consistent condom use within different sexualpartnershipsHusband or cohabitingpartnerMost recent non-payingpartnerAOR [95% CIs] P AOR [95% CIs] PINTERPERSONALAge differenceFSW older or same ageMale partner older (<5 years)Male partner older (5-9 years)Male partner older (10+ years)0.62 [0.22-1.73]0.65 [0.24-1.72]0.56 [0.19-1.63]1.0 (ref)0.7070.7780.469n/aDuration of relationship (years) 1.01 [0.96-1.06] 0.816 0.82 [0.68-0.97] 0.021Ever have stayed or lived with partner (vs never stayed/lived with partner) n/a 0.68 [0.13-3.56] 0.644Partner asks for anal sex (versus partner does not ask for anal sex) 1.32 [0.65-2.66] 0.440 / /Partner knows respondent is a sex worker (versus partner does not know respondent is sexworker)1.84 [1.02-3.32] 0.042 / /SOCIALMarital statusCurrently marriedUnmarried1.0 (ref)5.73 [2.79-11.76]/ /Age at first sex (years)<1515+1.0 (ref)1.12 [0.57-2.21]0.744 / /ENVIRONMENTALDistrictBelgaumBellaryBangaloreMysore0.06 [0.01-0.28]0.22 [0.10-0.52]0.14 [0.06-0.31]1.0 (ref)0.0290.8180.3230.03 [0.00-0.05]0.02 [0.00-0.27]0.02 [0.00-0.15]1.0 (ref)<0.0010.3700.025Literate (versus cannot read or write) 1.56 [0.84-2.89] 0.156 / /Place of solicitationHomeBrothelPublic places1.13 [0.54-2.36]1.46 [0.54-3.96]1.0 (ref)0.8530.5070.89 [0.39-2.01]0.70 [0.24-2.01]1.0 (ref)0.8930.579Multivariable (adjusted) odds ratios (AOR) and 95% confidence intervals (95%CIs): Multivariable relationships for the relationship between interpersonal, socialand environmental factors and consistent condom use with non-commercial sex partners of female sex workers in four districts in Karnataka state1,2,31n/a: Means that the factor was not available for analysis for that type of non-commercial partner2 The symbol / means that the variable was not significant in bivariate analysis and thus not included in multivariable analysis3Only variables that were significant for one of the two outcomes in bivariate were included in this table for brevityDeering et al. BMC Public Health 2011, 11(Suppl 6):S11http://www.biomedcentral.com/1471-2458/11/S6/S11Page 7 of 12women in sex work in southern India. Overall consistentcondom use (CCU) with non-commercial partners waslow and FSWs reported lower CCU with their husbandor cohabiting partner than with their non-paying partner.Both FSWs and their non-commercial partners werefound to be substantially connected to other types ofpartners through other sex partnerships. FSWs reportedthat a considerable proportion of these male partners hadother sex partners. These partners included wives, FSWsor other types of female partners – both within and out-side their local geographic settings (i.e., district of recruit-ment). These results highlight the vulnerability of FSWsto both acquisition and transmission of HIV/STIs withincomplex sexual networks, as well as the integral role ofFSWs’ non-commercial partners as bridge populationswho may facilitate the transmission of HIV to femalepartners outside the context of sex work.The longevity of the sexual partnerships with FSWs’non-paying partner appears to be particularly importantin determining CCU, with a longer relationship durationbeing associated with lower CCU. A more nuancedunderstanding of what the duration of the relationshiprepresents (e.g. increased trust, closeness or familiarity;decreased decision-making power or control) and howthese can be addressed in HIV/STI prevention program-ming is needed. Although FSWs in southern India arehighly economically vulnerable with few comparablywell-paying employment prospects [30], factors repre-senting the economic stability of the partner (e.g.employment status of the partner, or whether the part-ner provided economic support) were not significantlyassociated with CCU. Because the nature of non-com-mercial relationships is different from commercial rela-tionships, and the economic support, if it exists, is oftennon-monetary, the decision to use a condom may bemore influenced by interpersonal factors related to rela-tionship intimacy (e.g., trust, emotional closeness, poweror reproductive desires) than financial dependence. Thisis supported by studies of non-commercial partnershipsof FSWs in other settings [1,31]. However, economicdependence on the male partner is associated withlower condom use in other settings [23,32] and studiesof transactional sex arrangements have suggested thattrade-offs within these relationships occur, such asincreasing amounts of transfers of support (in terms ofmoney, goods, gifts) in exchange for risky behaviourthat is perceived as valuable to the male partner (suchas sex without a condom) [23,33], even after adjustingfor the duration of the relationship [23]. A better under-standing of the type and amount of transfers withinnon-commercial partnerships of FSWs in southernIndia, both quantitatively and qualitatively could help tobetter characterize the influence of economic depen-dence (or co-dependence) on condom use.While exposure to interventions has been found to bepositively associated with increased condom use byFSWs with their clients, including in our setting[4,12,34-37], [38], condom use within non-commercialpartnerships has not been a major focus of most inter-ventions and is rarely directly addressed effectively. Con-dom use within non-commercial partnerships thereforerepresents an important intervention point, particularlysince many non-commercial partners also have othercommercial or non-commercial sex partners. Interven-tions that include a focus on condom use within non-commercial partnerships of FSWs need to go beyondincreasing education and access to address issues of inti-macy and trust within relationships from the perspec-tives of women and men, as well as power disparitiesthat favour the male partner [15,17,39], [40]. This is par-ticularly true in settings where women have lower statusthan men and reduced economic opportunities, and tra-ditional social norms frame socio-cultural views of con-dom use [17,41], [42]. Interestingly, although educationwas associated with higher condom use in bivariate ana-lysis in this study, the effects were removed in multivari-able analysis. To better understand the complexity ofsocial and environmental factors influencing condomuse in non-commercial partnerships and how to developinterventions to increase condom use, conceptual frame-works that have been useful in explaining behaviourcould be employed [43-45]. Factors relating to the inten-tion to act, agency and decision-making power (i.e., per-ception of behavioural control) of women with respectto condom use should be assessed [46]. Furthermore,interventions must be constructed in ways that acknowl-edge traditional social norms surrounding condom use[17,41], [42] and the potential role of gender-based vio-lence [39,41] and sexual coercion [41] in lower condomuse. Qualitative research methods should be employedto better understand socio-cultural reasons for lowercondom use within non-commercial partnerships in thissetting.Interventions designed for clients of FSWs as well asFSWs have been observed to contribute to declines inSTI prevalence and increases in condom use [47,48].However, interventions designed for non-commercialmale partners are uncommon, despite the often signifi-cant role of non-commercial male partners in determin-ing if condoms are used within these partnerships[1,49]. In India, this is in part because such partners areoften hidden or difficult to access [15]. Husbands areparticularly inaccessible, since many are not aware oftheir partner’s involvement in sex work, while othernon-commercial partners may be actively involved inthe management of their partner’s sex work [15]. Fewerhusbands than main cohabiting partners in our studywere aware of their partner’s involvement in sex workDeering et al. BMC Public Health 2011, 11(Suppl 6):S11http://www.biomedcentral.com/1471-2458/11/S6/S11Page 8 of 12(23% versus 40%, p=0.01). It may be more effective todesign male-focused interventions specifically for othernon-commercial partners of FSWs, in this and otherstudy settings. There is some evidence for the success ofmale-focused interventions which address social normsand gender-based violence in increasing condom use,including in India (the Sonagachi Project) and SouthAfrica (Stepping Stones) [50,51]. Targeting youngermales may be particularly effective in terms of changingsocial norms surrounding sexual behaviour for men andwomen in India. A systematic review of six couples-focused behavioural interventions (outside the contextof sex work) found that involvement in the programswas associated with reduced unprotected sex [52], sug-gesting that these types of interventions could be benefi-cial and should be explored. In some areas targeted bythe Avahan AIDS Initiative in southern India, anincreasing focus of the program has been on increasingsafety within non-commercial partnerships of FSWs.Avahan’s primary focus in terms of increasing condomuse, however, has been for condom use within commer-cial partnerships. In this study, condom use with non-commercial partners was statistically significantly differ-ent in multivariable analysis according to the districtwhere women were recruited into the study. In particu-lar, condom use was higher in Mysore district comparedto the other districts. These differences may be due todifferences in program implementation or timing of theintervention implemented in each district. Avahan hasbeen the only intervention in Mysore district, but wasnot the first (though it is now the only) intervention inother districts. Notably, though, a recent study of threedistricts in Karnataka state (Mysore, Belgaum and Bel-lary) found that condom use at last sex with non-com-mercial (non-marital) partners of FSWs has increasedsignificantly (24.4% to 55.9%) over six years of the inter-vention [53], although this was not the case earlier inthe intervention [12]. The largest increases wereobserved in Belgaum and Mysore. These results indicatethat it may take longer for interventions targeted towardFSWs to have an effect on condom use within non-commercial compared to commercial partnerships, butthat positive results can be observed. Additionalresearch should be conducted to better understand thesocial and structural factors that operate within eachdistrict on a macro level to influence condom use, andthe intersecting relationship between these factors andintervention impact. Individual-level variables such asthose explored in this study may not necessarily capturethese influences. Lower condom use with non-commer-cial relative to commercial partners persists and sus-tained interventions targeted toward increasing condomuse within non-commercial partnerships should con-tinue to be explored and developed. The use of HIVprevention methods that women have more control over(i.e., microbicides, female condom) should be investi-gated in this study population and within non-commer-cial partnerships.In our study, CCU was almost two-fold higher withFSWs’ husband or cohabiting partner when this partnerknew the FSW was in sex work. Condom use could behigher in these relationships because of an increasedawareness of the risks incurred by these women by themale partner. This could also be due to greater exposureand involvement in HIV/STI programming designed forFSWs, or increased access by HIV/STI programs tomale partners. Sex work occupational stigma, whichinfluences women to hide their sex work status fromtheir partners and families, has increasingly been postu-lated as a major barrier to health access for FSWs[54,55]. These results provide support for sex workbeing recognized as a more legitimate occupation,where women do not feel obligated to hide their workfrom their non-commercial partners. However, disclo-sure of sex work needs to be understood within the con-text of local socio-cultural views and social normsregarding women’s status and sex work, to help ensurethat women’s safety is not compromised by disclosure.Sentinel surveillance and observational studies suggestthat HIV and STIs have decreased among FSWs in Kar-nataka state since Avahan was introduced [12,56], andmathematical modelling has indicated that the increasein condom use among FSWs with their clients after theintervention was introduced is consistent with decreas-ing HIV epidemiological trends over 2-3 rounds of sur-vey data collection [57,58]. Although commercial sexpartnerships of FSWs play a large role in the spread ofHIV [7,59], the lack of information on non-commercialpartners makes it difficult to assess their role in thespread of HIV through local sexual networks, and theiroverall potential contribution to HIV epidemics. How-ever, since condom use remains low in non-commercialpartnerships in this setting, to better inform the contri-bution of non-commercial partnerships to the spread ofHIV, future empirical studies should collect informationon the sexual behaviour of non-commercial partnerswith other partners (e.g., numbers and types of otherpartners, frequency of sexual contacts, condom use) andthe presence of HIV infection among non-commercialpartners of FSWs. Since almost all information on non-commercial partners has been collected second-handfrom FSWs rather than from the perspective of theirmale partners, studies should be conducted with men.There are several limitations to this study. The studyis based in four districts in Karnataka state, southernIndia, and may not be generalizable to other regions inIndia. It is based on self-reported data from cross-sec-tional surveys, and self-reported data may be subject toDeering et al. BMC Public Health 2011, 11(Suppl 6):S11http://www.biomedcentral.com/1471-2458/11/S6/S11Page 9 of 12social desirability bias [60]. However, our sample size waslarge, particularly for a marginalized and hidden popula-tion of FSWs, and the cluster sampling design was aimedto make the sample as representative as possible.Reported condom use was substantially lower with non-commercial rather than commercial partnerships, indi-cating that women may have been comfortable reportinghigher-risk behaviour with these partners. At the sametime, it may be more socially acceptable for women toreport lower condom use with non-commercial partners,since women as well as men may associate condom usewith infidelity or reduced trust. We were unable to con-trol for fertility desires of respondents, which may affectlevels of condom use with non-commercial sex partners[23]. However, since the majority of respondentsreported using some kind of birth control for family plan-ning purposes, this indicates that most women were notplanning on becoming pregnant. Finally, developingquestionnaires grounded in theoretical frameworks pre-viously used in similar populations and settings could behelpful in explaining the reasons for condom use [46].ConclusionsThe results from this study have revealed important pat-terns and interpersonal determinants of condom usewithin non-commercial partnerships of women in sexwork. Integrated structural and community-driven sex-ual and reproductive health and HIV/STI preventionprograms that include a focus on gender and reducesocial stigma surrounding sex work are needed in set-tings with high HIV prevalence among FSWs and theirnon-commercial partners.Additional materialAdditional file 1: Sample characteristics of social and environmentalfactorsSample characteristics of social and environmental factors:Sample characteristics according to the type of non-commercialpartner of female sex workers (FSWs) in four districts in Karnatakastate, including FSWs’ husband or main cohabiting partner or theirmost recent non-paying partner (who is neither a husband nor themain cohabiting partner).AcknowledgementsKND is supported by a Postdoctoral Research Fellowship (Bisby Award) fromthe Canadian Institutes of Health Research. Support for this study wasprovided by the Bill and Melinda Gates Foundation. The views expressedherein are those of the authors and do not necessarily reflect the officialpolicy or position of the Bill and Melinda Gates Foundation.This article has been published as part of BMC Public Health Volume 11Supplement 6, 2011: Learning from large scale prevention efforts – findingsfrom Avahan. The full contents of the supplement are available online atURL.Author details1Division of AIDS, Department of Medicine, Faculty of Medicine, University ofBritish Columbia, Vancouver, Canada. 2Karnataka Health Promotion Trust,Bangalore, India. 3URESP, Centre de recherche FRSQ du CHA universitaire deQuébec, Québec, Canada. 4Department of Medical Microbiology, Universityof Manitoba, Winnipeg, Canada. 5Department of Community HealthSciences, University of Manitoba, Winnipeg, Canada. 6BC Centre forExcellence in HIV/AIDS, Faculty of Medicine, University of British Columbia,Vancouver, Canada. 7HIV and STI Department, Health Protection Services –Colindale, Health Protection Agency, London, UK. 8Department of InfectiousDiseases Epidemiology, Imperial College, London, UK.Authors’ contributionsKND contributed to the conceptual design of the study, conducted thestudy and the analysis and drafted the manuscript; JB and KS participated inthe conceptual design of the study and coordination, made substantialcontributions in the interpretation of data; PB, SM, SYS, MCB, CL and MAmade substantial contributions in the interpretation of data and criticallyrevised the manuscript for important intellectual content; BMR, KG, SR, RWmade substantial contributions to the acquisition and management of thedata. All authors read and approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Published: 29 December 2011References1. Murray L, Moreno L, Rosario S, Ellen J, Sweat M, Kerrigan D: The role ofrelationship intimacy in consistent condom use among female sexworkers and their regular paying partners in the Dominican Republic.AIDS and Behaviour 2007, 11:463-470.2. Voeten HACM, Egesah OB, Varkevisser CM, Habberma JDF: Female sexworkers and unsafe sex in urban and rural Nyanza, Kenya: regularpartners may contribute more to HIV transmission than clients. TropicalMedicine and International Health 2007, 12:174-182.3. Stoebenau K, Hindin MJ, Nathanson CA, Rakotoarison PG, Razafintsalama V:“... But Then He Became My Sipa": The Implications of RelationshipFluidity for Condom Use Among Women Sex Workers in Antananarivo,Madagascar. Am J Public Health 2009, 99:811-819.4. 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Hanck SE, Blankenship KM, Irwin KS, West BS, Kershaw T: Assessment ofSelf-Reported Sexual Behavior and Condom Use Among Female SexWorkers in India Using a Polling Box Approach: A Preliminary Report.Sexually Transmitted Diseases 2008, 35:489-494.doi:10.1186/1471-2458-11-S6-S11Cite this article as: Deering et al.: Condom use within non-commercialpartnerships of female sex workers in southern India. BMC Public Health2011 11(Suppl 6):S11.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitDeering et al. BMC Public Health 2011, 11(Suppl 6):S11http://www.biomedcentral.com/1471-2458/11/S6/S11Page 12 of 12

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