The Relationship Between HIV_Sexually Transmitted Infection Risk and Alcohol Use During Commercial Sex Episodes: Results From the Study of Female Commercial Sex Workers in the Philippines

Abstract

The HIV/Sexually Transmitted Infection (STI) risk associated with alcohol use between female commercial sex workers (FCSWs) and their customers has been understudied. We examined this relationship for 1,114 FCSWs aged 15-54 with data collected during the baseline study period (1994 to 1998) in four southern provinces of the Philippines. Two alcohol-related risk situations during commercial sex episodes were examined: prior alcohol use by an FCSW and perceived intoxication in a customer. The influence of sociodemographic variables on sexual risk behaviors was also studied. Multiple sexual risk behaviors were observed with more frequency for FCSWs if alcohol was used before commercial sex or if the episode involved a customer perceived to be intoxicated. Forty-two percent of FCSWs who had sex with an intoxicated customer were STI positive, significantly more than FCSWs who did not have sex with an intoxicated customer (28%, p < .01). Similar significant differences were found for FCSWs who did not consume alcohol before having sex and were STI positive (29%) versus FCSW who did consume alcohol before sex and were STI positive (33%, p < .01). Our analyses reinforce accumulating evidence in the field that sexual risk reduction interventions need to go beyond the behaviors of individual FCSWs to meet the layering of risks such as observed in this study. Multilevel strategies targeting customer substance use and other situational and structural factors have proven to be pivotal mediators in our other research with this population. These experiences and the limitations of this study are discussed.

Full text

Substance Use & Misuse, 41:1509–1533
Copyright
© 2006 Informa Healthcare
ISSN: 1082-6084 (print); 1532-2491 (online)
DOI: 10.1080/10826080600846284
The Relationship Between HIV/Sexually
Transmitted Infection Risk and Alcohol
Use During Commercial Sex Episodes:
Results From the Study of Female
Commercial Sex Workers in the Philippines
CHI CHIAO,
1
DONALD E. MORISKY,
2
RHONDA ROSENBERG,
3
KATE KSOBIECH,
4
AND
ROBERT MALOW
3
1
National Cheng Kung University, Tainan, Taiwan, ROC
2
University of California, Los Angeles, Los Angeles, CA, USA
3
Florida International University, Miami, FL, USA
4
Marquette University, Milwaukee, WI, USA
The HIV/Sexually Transmitted Infection (STI) risk associated with alcohol use between
female commercial sex workers (FCSWs) and their customers has been understudied. We
examined this relationship for 1,114 FCSWs aged 15–54 with data collected during the
baseline study period (1994 to 1998) in four southern provinces of the Philippines. Two
alcohol-related risk situations during commercial sex episodes were examined: prior
alcohol use by an FCSW and perceived intoxication in a customer. The influence of
sociodemographic variables on sexual risk behaviors was also studied. Multiple sexual
risk behaviors were observed with more frequency for FCSWs if alcohol was used
before commercial sex or if the episode involved a customer perceived to be intoxicated.
Forty-two percent of FCSWs who had sex with an intoxicated customer were STI positive,
significantly more than FCSWs who did not have sex with an intoxicated customer (28%,
p < .01). Similar significant differences were found for FCSWs who did not consume
alcohol before having sex and were STI positive (29%) versus FCSW who did consume
alcohol before sex and were STI positive (33%, p < .01). Our analyses reinforce
accumulating evidence in the field that sexual risk reduction interventions need to go
beyond the behaviors of individual FCSWs to meet the layering of risks such as observed
in this study. Multilevel strategies targeting customer substance use and other situational
and structural factors have proven to be pivotal mediators in our other research with
this population. These experiences and the limitations of this study are discussed.
Keywords environmental factors; female commercial sex workers (FCSWs); HIV;
Philippines; sex workers (indirect, freelance); sexually transmitted infections (STIs);
situational factors
Introduction
Throughout the world, governments are striving to initiate programs and confront the threat
of HIV/AIDS. In India, perhaps somewhat belatedly, the government is now recognizing
Address correspondence to Dr. Donald E. Morisky, Department of Community Health Sciences
at UCLA School of Public Health, 650 Charles E. Young Drive South, Box 951772, 26-070 CHS,
Los Angeles, CA 90095-1772, USA. E-mail: dmorisky@ucla.edu
1509

1510 Chiao et al.
the importance of incorporating sociocultural and behavioral contexts in promoting the
use of condoms as an HIV/AIDS prevention strategy even among heterosexual couples
(Bhattacharya, 2004). In China, efforts are underway to encourage condom use by focusing
on high-risk populations such as hospitality girls working in licensed entertainment
establishments (Wei et al., 2004).
In the Philippines, where HIV/AIDS has not yet become a generalized epidemic
(UNAIDS, 2003), the government is moving aggressively to confront the problem by
instituting an action plan that emphasizes local responsiveness by governmental agencies
and nongovernmental organizations, the incorporation of HIV/AIDS education into the
school curriculum, and laws forbidding discrimination against persons with HIV/AIDS or
those who belong to at-risk groups. Infection rates in the usual risk groups (e.g., sex workers,
men who have sex with men, sexually transmitted infection [STI] clients, returning overseas
workers) remain below 1% throughout most of the Philippines (Mateo et al., 2004) and
up to 2% among registered female sex workers (UNAIDS, 2003). This low HIV incidence
rate is often attributed to the relatively low number of full-time sex workers, the relatively
low average number of clients per night, the low proportion of injectors among drug users,
the early multisector response to the epidemic, and/or the establishment of social hygiene
clinics for sex workers. A recent study by Du Mont and McGregor (2004) concluded that
social and structural factors are involved in the decisions of female commercial sex workers
(FCSWs) regarding medical examinations, even when required by law. However, rates of
STIs, multiple sex partners, and injection drug use with needle sharing are increasing,
suggesting that an explosive epidemic could still occur if the virus is introduced into key
at-risk populations. One need only look to Vietnam and Indonesia to provide examples of
delayed epidemics of HIV/AIDS; a similar trajectory could also occur in the Philippines
(Mateo et al., 2004). In those countries, government inactivity and “denial” of the potential
HIV/ADS problem in its infancy exacerbated problem situations and led to larger rates of
infection in subsequent years.
Not surprisingly, early HIV prevention campaigns focused primarily on individual
knowledge and attitudes in an effort to produce changes in personal behaviors that contribute
to HIV risk (Catania et al., 1989). However, it has become increasingly evident that
sustainable outcomes are more likely when interventions include multilevel and ecological
components that reinforce individual-level changes (Bandura, 2004; Poundstone et al.,
2004). Researchers have applied various theoretical structures, integrating situational
determinants into individual-level targeted HIV behavioral interventions (Kelly et al.,
1993). Although not formally acknowledged, many HIV prevention interventions have
documented the success of situational and environmental factors as determinants of behavior
(Fishbein, 2000; Kalichman et al., 1999; Melkote et al., 2000; Morisky et al., 2002;
Nyamathi et al., 1995). Demographic variables, local resource constraints, familial and
social support, institutional reinforcements, and public service linkages have all been
implicated in affecting behavioral changes and have been increasingly examined and
targeted by interventionists seeking more contextually oriented designs. These efforts
echo ideas long expressed in other fields and disciplines (Tuan, 1974) that emphasize
the “situated” nature of human populations and the consequent need for social ecological
approaches to inquiry and policy action.
The most relied on HIV risk reduction strategy globally has been the promotion
of consistent and correct condom use (Carlin and Boag, 1995), which is often the
primary dependent variable (i.e., quantified measurable “outcome”) in many studies
(Fishbein and Pequegnat, 2000; Kuntolbutra, 1996). Condom use has been linked to
many dispositional influences, including motivation, negotiation skills, sexual self-efficacy,

HIV/STI Risk and Alcohol Use Among Sex Workers 1511
knowledge of HIV transmission, and one’s perceived risk of contracting HIV. As Auerbach
and Coates (2000) have made explicit, however, the current state of HIV prevention
intervention science encompasses more than protective technologies and behavior. Specific
counseling, normative, social, and institutional strategies now exist to enable individuals
and communities to make protective choices and act on prevention messages in their real
lives. The situational and cultural barriers that these strategies address have moved the
science of HIV intervention forward. Situational determinants clearly relate to condom
use. They may include structural characteristics inherent in the environment, such as a
pro-condom attitude in a sexually oriented workplace, an employer’s positive attitudes
toward condom use, consent of the sexual partner, and the availability/price of condoms.
In the Philippines, sex work is not legal. Nevertheless, establishment-based FCSWs are
required by the government to register at local social hygiene clinics (SHCs) and to undergo
weekly or bimonthly check-up appointments. Personnel from the City Health Office make
unannounced visits to the various establishments in the community to validate that all
FCSWs have a registration card on file. Owners and managers of establishments found not
to adhere to this policy are fined, and after three violations the establishment is closed for
1 week (Morisky et al., 2002).
In the Philippines, FCSWs are employed in bars, nightclubs, disco houses, karaoke
TV centers, and massage parlors. Employees in these establishments are most often called
indirect sex workers rather than brothel-based or free-lance direct sex workers. Over a
decade ago it was estimated that there were more than 225,000 registered establishment-
based FCSWs in the Philippines (Tan, 1993). Abellanosa and Nichter (1996) have reported
that FCSWs who remain unregistered at a SHC are seven times less likely to use condoms
with their customers than registered FCSWs and tend to have sex with three times as many
customers than their registered counterparts.
Establishment-based FCSWs often work under conditions that promote condom use
between customer and client (Albert et al., 1995; Pyett et al., 1996). Commercial sex work
establishments thus serve as the situational context for condom use norms and practices of
FCSWs. Previous interventions with establishments (brothels) in Indonesia and Thailand
have led to increased condom use among FCSWs (Ford et al., 1996; Visrutaratna et al.,
1995). Our prior research also identified establishment policies as an important factor
influencing condom use among FCSWs (Morisky et al., 1998; Tiglao et al., 1997). As a
situational determinant, alcohol use might well induce a variety of risky sexual behaviors
in the FCSW and/or the customer. However, research on alcohol use and unsafe sex has
failed to document a consistent relationship.
Findings from such research, primarily with men who have sex with men, indicate that
personality and contextual factors may mediate this relationship (McKirnan et al., 1996;
Mutchler, 2000; Weinhardt and Carey, 2000), highlighting a need for qualitative analyses
of the diverse roles that alcohol consumption plays in the sexual practices of men who have
sex with men. For men who have sex with men, alcohol use may facilitate behaviors that
would otherwise elicit shame or guilt based on internalized social norms and proscriptions.
Alcohol consumption and sexual behaviors may become so intertwined for some individuals
that there is great difficulty in performing sexually when sober.
Although some studies document a significant relationship between alcohol use and
risky sexual behaviors among HIV-infected men, others have not (Variable et al., 2004).
A recent systematic review of the relevant literature failed to find evidence of a direct
link between alcohol use and risky sex (Weinhardt and Carey, 2000). Although alcohol
consumption has not been consistently linked to unsafe sex in a causal manner, some
researchers have reported that alcohol intoxication influences contextual factors related

1512 Chiao et al.
to sexual risk activities (McKirnan et al., 1996; Mutchler, 2000; Parsons et al., 2004).
Specifically, alcohol use may focus attention on the present context, blunting awareness
of prevailing social norms or an individual’s own code of acceptable behavior (Steele and
Josephs, 1990). Alcohol use may also impact one’s normal behavioral self-monitoring while
subsequently exacerbating the potential influences of environmental stimulations. Further,
the expectancies from the effects of alcohol may synergize risky sex among HIV-infected
men if the assumption is made that prompting alcohol use will positively affect their sexual
experiences (Kalichman et al., 2002). Just as Zinberg (1984) made the field sensitive to
considering the interaction of set, setting, and drug use with regard to a “drug experience,”
so too can different endogenous and exogenous factors (different types of partners, types
of sexual acts performed, types and levels of risk taking, and whether or not condoms are
used, etc.) and their interactions influence HIV/STI among commercial sex workers who
consume alcohol.
This study used an ecological perspective to analyze putative personal and situational
influences of alcohol use among FCSWs and their customers in the Philippines. Specifically,
we focused on the impact of alcohol consumption by FCSWs and their customers before
the commercial sexual episode. Causal modeling was used to examine the psychosocial
predictors (a term that implies both personal and situational influences) of AIDS risk
behaviors similar to Nyamathi et al. (1995) and Stein and Nyamathi (2000). Personal
factors included the FCSWs’ individual sexual health risks, perceived susceptibility to
HIV, and alcohol and drug use–related behaviors. Situational factors were operationalized
as establishment and/or manager policies concerning condom use policies between sex
worker and client as well as other structural characteristics inherent in a woman’s situation,
such as exposure to AIDS education efforts. Situational as well as personal influences
were hypothesized to be operating among women clustered within establishments. This
study also sought to assess the extent to which socioeconomic groups, psychosocial traits,
and sexual practices were related to situational influences, including a FCSW’s situational
alcohol use behavior.
Methods
Study Population
From the outset, an advisory task force at each intervention location was organized through
the University of the Philippines, College of Public Health. Advisory committee members
consisted of the Regional Health Officer, City Health Officer, representatives from the
Mayor’s Office, representatives from the local HIV/AIDS organizations (both private and
public), community leaders, and representatives from the establishments participating in
the study. Meetings were held quarterly throughout the duration of the investigation. All
these individuals, as well as the FCSWs who agreed to participate, were made aware of
the benefits that might accrue via a scientific evaluation of the type and prevalence of STIs
in the Social Hygiene Clinic and the possible future distribution of educational materials
developed during and after the completion of the study.
Women were recruited from entertainment-related establishments on four southern
Philippine islands, southern Luzon, Cebu, Ilo-Ilo, and northern Mindanao, from 1994
to 1998. Approximately 98% of the women provided informed consent after receiving
culturally sensitive and appropriate human subjects protection information regarding the
study and protocol (e.g., objectives, potential risks, and benefits) approved by UCLA

HIV/STI Risk and Alcohol Use Among Sex Workers 1513
and the University of the Philippines. Of 1,360 women interviewed, the data of 76 were
excluded from our analyses because they denied commercial penetrative vaginal, anal, or
oral intercourse. The sample size was further reduced to 1,114 by excluding an additional
170 women who denied any alcohol consumption.
Table 1 displays the sample’s sociodemographic characteristics. The FCSWs averaged
23.5 years of age (range, 15–54), 8.96 years of schooling, and 12.47 months of sex work
employment, with a mean weekly income of 1237.32 pesos (approximately $48.83 a week
in U.S. dollars, and the average per capita income in the Philippines was $952.98 a year
in U.S. dollars). Eight percent of the FCSWs were street workers, 67% bar workers, and
30% nonbar workers. Seventy percent reported they were unmarried or lived separately
from their husbands. FCSWs reported often consuming alcohol, albeit less frequently with
their customers, and seldom used other illicit substances, particularly injection drugs (4%).
Fully 19% had consumed alcohol before commercial sexual encounters, and 37% reported
engaging in sexual acts with inebriated customers. FCSWs reported an average of two
vaginal intercourse acts in the week before the interview. From a medical record review,
it was found that 31% of the FCSW sample was ever infected with an STI and 14%
experienced STI reinfection during the 8-month investigation period.
Major Measures
Table 2 provides a description of measurements used in this study. STI prevalence was
determined by the local SHC physicians who examined FCSWs. The STI prevalence
measure displayed in Table 1 was coded by the research assistant: 1, infection present
during 8 months of data collection; 0, no infection present; and 8, infection status unknown.
Alcohol use was assessed during transactional intercourse via asking FCSWs whether
they ever drank alcohol before sexual contact with customers and whether they ever had
sex when customers were perceived to be intoxicated. On a five-point Likert scale (never
to always) FCSWs were also asked, “How often do you have beer or drinks containing
alcohol?” and “How often do you drink beer or alcohol with your customers?”
Drug use was measured through a five-point Likert scale (never to always) item, “How
often do you take drugs like marijuana, cocaine, or amphetamines?” and an item, “Have
you ever injected a drug by sticking a needle into your arm?” Affirmative responders to the
latter were further asked, “How often do you use injectable drugs?”
Condom use was assessed by six 5-point Likert scale items pertaining to how often
FCSW “used a condom when engaging in vaginal sex,” “whether they suggested using a
condom to their partner,” and “carry a condom on their person.” In our prior work (Morisky
et al., 2002a), the scale showed an alpha reliability of .80. After reverse-coded adjustments
were made, responses were summed, with higher scores reflecting a greater likelihood of
using condoms. FCSWs were also asked, “In the past month, have you had a condom fall
off inside you?”
Other measures were derived from asking FCSWs about perceived HIV/AIDS risk
and practice. For example, a five-point Likert scale question assessed a FCSW’s level of
worries about HIVAIDS: “How worried are you about getting AIDS?” Entertainment estab-
lishment managers were surveyed about AIDS education provided by their establishment
including a dichotomous item on whether an education workshop operated within their
establishment. Additional data were also gathered regarding the attitudes and behaviors
of managers/owners and supervisors as well as the FCSWs perceptions of the manager’s

1514 Chiao et al.
Table 1
Selected characteristics of study sample (n = 1,114)
Mean SD Range
Age in years 23.49 5.18 15–54
Education in years 8.96 2.17 0–14
Weekly wage in pesos 1,237.32 1,158.47 50–9,000
Length of work in months 12.47 20.30 0–240
Frequency of vaginal intercourse for past week 1.99 3.36 0–40
Frequency of drinking alcohol (1: once or twice a
month; 4: everyday)
3.06 .89 1–4
Frequency of drinking alcohol with customers
(1: never; 5: always)
2.83 1.96 1–5
Frequency of drug use (1: never; 5: always) 1.30 .65 1–5
N(%)
Marital status
Single 571 (52%)
Single but living with a boyfriend 215 (19%)
Separated 198 (18%)
Married 125 (11%)
Workplace:
Street worker 82 (8%)
Bar-based worker 744 (67%)
Non–bar-based worker 288 (26%)
Township
Legaspi 231 (21%)
Cagayan de Oro 378 (34%)
Cebu 299 (27%)
Ilo-Ilo 206 (18%)
STI prevalence in 8 months
No infection 514 (46%)
Infection 345 (31%)
Unknown status 255 (23%)
STI reinfection (% yes) 152 (14%)
Drug injection (% yes) 39 (4%)
Alcohol intake prior sex
Yes 215 (19%)
No 623 (56%)
No response 276 (25%)
Sex with an inebriated customer
Yes 417 (37%)
No 490 (44%)
No response 207 (19%)
Percentage may not add up to 100 due to rounding.

Table 2
Description of measurements
Variable Category Description
Individual sociodemographics Individual socio-demographic characteristics are
derived from Health Belief Model (Strecher
and Rosenstock, 1997) and empirical-based
evidence.
Age Continuous variable measured in years
Education attainment Continuous variable measured in years
Weekly wage Continuous variable measured in pesos
Length of works Continuous variable measured in months
Marital status Categorical variable with four categories:
1. Single
2. Single but living with a boyfriend
3. Separated
4. Married
Alcohol and drug use Studies provided empirical evidence for the
association between alcohol and drug use and
risky sexual behaviors.
Frequency of drinking alcohol Continuous variable measured by 5-point Likert scale
from “never” (coded as 1) to “always” (coded as 5)
Frequency of drinking alcohol
with clients
Continuous variable measured by 5-point Likert scale
from “never” (coded as 1) to “always” (coded as 5)
Frequency of drug use Continuous variable measured by 5-point Likert scale
from “once or twice a month” (coded as 1) to
“everyday” (coded as 5)
Drug injection Categorical variable with dichotomous response
(yes/no)
Sexual health risks Studies provided empirical evidence that
engagements of risky sexual behaviors are
contingent to situations (Morisky et al., 2002).
Frequency of vaginal intercourse
for past week
Continuous variable measured in number of times per
week.
Likelihood of using condoms Condom use scale
Condom off inside Categorical variable with dichotomous response
(yes/no)
(Continued on next page)
1515

Table 2
Description of measurements (Continued)
Variable Category Description
HIV/AIDS Practice Individual protective health practice and
perceived risk variable is derived from the
AIDS risk reduction model (ARRM) (Catania
et al. (1990) and Health Belief Model (Strecher
and Rosenstock, 1997).
Contextual-level factors are derived from social
ecological theory (McLeroy, et al., 1988;
Poundstone et al., 2004).
HIV test Categorical variable with dichotomous response
(yes/no)
HIV/AIDS Perception
AIDS perceived risk Continuous variable measured by 5-point Likert scale
from “not at all worried” (coded as 1) to “extremely
worried” (coded as 5)
Contextual-level factors
Workplace Categorical variable with three categories:
1. Street workers
2. Bar-based workers
3. Non-bar based workers
AIDS education workshop Categorical variable with dichotomous response
(yes/no).
Township Categorical variable with four categories:
1. Legaspi
2. Cagayan de Oro
3. Cebu
4. Ilo-Ilo
1516

HIV/STI Risk and Alcohol Use Among Sex Workers 1517
attitudes, beliefs, and support provided when negotiating type of sex with the customer.
These data are not the focus of the present investigation and therefore are not discussed
further in the present article.
Data Analysis
Using Stata-PC version 8.0 software (StataCorp, 2004), data analyses explored the risk
factors in two specific situations that involved alcohol use proximal to sexual contact.
Bivariate analyses with chi-square tests for categorical variables and F tests for continuous
variables were used to examine the distribution across the subgroups of these two specific
alcohol use circumstances and determine the statistical significance of all comparisons
(individual sociodemographics, sexual activity, and structural factors) from the selected
subgroups.
We also explored whether a proposed ecological model could predict various alcohol
use behaviors before sexual contact. Given categorical dependent variables with three levels,
we used multinomial logistic regression with robust estimates to evaluate this model while
adjusting for the cluster effect of workplace. For an outcome variable with three levels, two
sets of contrasts were performed as well with the Wald test for each predictor. For example,
in the first selected situation, the first contrast was comparing FCSWs reporting alcohol
intake before sex with customers with those who did not. In the second contrast, FCSWs
who reported not having sex with customers after alcohol intake were compared with those
who did not respond to the item.
Results
Background Information
We analyzed the relationship between unsafe sexual behaviors and alcohol use in one risk
situation defined by whether the FCSW ingested alcohol before commercial sex and a
second risk situation distinguished by whether a customer was reported “drunk” by the
FCSW. As displayed in Table 3, we found sociodemographic differences pertaining to
age, education, and weekly income. FCSWs having sex with inebriated customers were
older, earned higher wages, and worked for longer periods as sex workers than FCSWs
who reported having alcohol intake before commercial sex. FCSWs who reported having
sex with intoxicated customers were more likely to be street workers or non–bar-based
employees than those who did not (χ
2
(4)
= 129.04; p < .01).
STI Status
There was a clear contrast between the two situations previously described with respect to
the STI status of FCSWs, with the second situation emerging as the most dominant. Using
an 8-month interval, 31% of FCSWs reported being diagnosed with an STI by a trained
medical professional. As displayed in Figure 1, this STI rate was significantly higher among
the FCSWs who reported having sex with an intoxicated customer (42%) than those who
did not (28%) but was not associated with the likelihood of whether or not alcohol was
used by the FCSWs before sex. An additional significant finding was that 33% of FCSWs
who reported alcohol intake before sex with a customer acquired STIs versus 29% of those
who denied alcohol intake before sex.

Table 3
Selected sociodemographics by alcohol intake behaviors in sexual contact of female commercial sex workers (n = 1,114)
Risk situation 1: alcohol intakes prior to commercial sex Risk situation 2: commercial sex with sober clients
No Yes No response No Yes No response
Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Age in years 23.49 (5.17) 23.74 (5.25) 23.28 (5.17) 23.05 (4.88) 24.29 (5.80) 22.90 (4.30)
Education in years 8.76 (2.23) 8.61 (1.93) 9.69 (2.04) 8.72 (2.18) 8.81 (2.10) 9.84 (2.05)
Weekly wage in pesos 1,169.11 (1,114.16) 1,275.35 (1,104.50) 1,363.24 (1,285.08) 1,076.29 (1,051.19) 1,504.47 (1,418.05) 1,078.53 (569.04)
Length of work in months 11.46 (19.01) 15.47 (21.83) 12.41 (21.69) 9.65 (19.56) 17.79 (23.60) 8.40 (10.04)
N (%) N (%) N (%) N (%) N (%) N (%)
Marital status
Single 312 (50%) 102 (48%) 157 (57%) 254 (52%) 192 (46%) 152 (61%)
Single but living
with a boy friend
113 (18%) 54 (25%) 48 (17%) 81 (17%) 102 (25%) 32 (16%)
Separated 121 (20%) 40 (19%) 37 (13%) 88 (18%) 90 (22%) 20 (10%)
Married 74 (12%) 18 (8%) 33 (12%) 66 (14%) 30 (7%) 29 (14%)
Workplace
Street worker 29 (5%) 24 (11%) 29 (11%) 22 (5%) 56 (13%) 4 (2%)
Bar-based worker 407 (65%) 139 (65%) 198 (72%) 354 (72%) 202 (48%) 188 (91%)
Non–bar-based worker 187 (30%) 52 (24%) 49 (18%) 114 (23%) 159 (38%) 15 (7%)
Township
Legaspi 226 (36%) 4 (2%) 1 (0%) 229 (47%) 1 (0%) 1 (0%)
Cagayan de Oro 155 (25%) 97 (45%) 126 (46%) 57 (12%) 190 (46%) 131 (63%)
Cebu 196 (31%) 67 (31%) 36 (13%) 153 (31%) 86 (21%) 60 (29%)
Ilo-Ilo 46 (7%) 47 (22%) 113 (41%) 51 (10%) 140 (34%) 15 (7%)
Percentage may not add up to 100 due to rounding.
1518

HIV/STI Risk and Alcohol Use Among Sex Workers 1519
Figure 1. STI prevalence by alcohol use behaviors with commercial sexual contact, including
alcohol intake before sex (χ
2
(4)
= 72.96; p < .01) and sex with inebriated customers (χ
2
(4)
= 125.36;
p < .01).
Sexual Risk and Alcohol and Drug Use
Table 4 presents data for the two specific alcohol use circumstances reported by FCSWs.
As displayed, those who drank alcohol before engaging in commercial sex were drinking
alcohol with their customers more often, using illicit drugs more frequently, and engaging
in more sexual activity than the nondrinking alcohol categories in risk situation 1. In risk
situation 2 the FCSWs who had sex with an intoxicated customer were also more likely
to use drugs and had higher rates of sexual activity compared with those FCSWs who did
not have commercial sex with an intoxicated customers or did not respond the question. In
addition, these groups of FCSWs were more likely to report that the condom fell off during
commercial sex, even as a more frequent use of condoms was reported.
Ecological Model Predicting Alcohol Use With Commercial Sex
Risk Situation 1. The ecological models predicting alcohol use in the first commercial sex
situation were statistically significant: Wald χ
2
(28)
= 332.35 (p < .01). Table 5 presents
the first contrast, comparing FCSWs who had alcohol intake before commercial sex with
those who did not have alcohol intake before commercial sex (reference group). FCSWs’
alcohol and drug use significantly differentiated the group membership of this first contrast,
such that FCSWs who used alcohol and drugs more frequently were more likely to drink
alcohol before commercial sex. The FCSWs who did not have an HIV test were more likely
to consume alcohol before commercial sex as opposed to the reference group. Those who
used condoms were far more likely to drink alcohol with a sex customer in comparison
with those who did not drink with the customer, whereas those who used condoms were
far more likely to be nonrespondents on alcohol use question. Workplaces also predicted
group membership: Street workers were more likely to drink alcohol before commercial
sex as opposed to the non–bar workers.

Table 4
Risk behaviors by alcohol intake behaviors in commercial sexual contact of female commercial sex workers (n = 1,114)
Risk situation 1 Risk situation 2
No Yes No response No Yes No response
Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Alcohol and drug use
a
Frequency of drinking
alcohol
3.08 (.85) 3.34 (.74) 2.80 (1.01) 3.13 (.82) 3.08 (.90) 2.87 (1.01)
Frequency of drinking
alcohol with customer
2.90 (1.38) 3.21 (1.40) 2.37 (1.34) 3.10 (1.34) 2.81 (1.41) 2.23 (1.35)
Frequency of drug use 1.20 (.57) 1.48 (.80) 1.39 (.66) 1.21 (.56) 1.47 (.75) 1.20 (.55)
Sexual health risks
Frequency of vaginal
intercourse for past week
1.86 (3.15) 2.51 (3.48) 1.89 (3.67) 1.62 (2.20) 2.95 (4.56) .95 (2.02)
Likelihood of using condoms
b
.37 (.32) .56 (.23) .28 (.28) .32 (.32) .57 (.22) .15 (.23)
HIV/AIDS perception
AIDS perceived risk
c
3.92 (1.10) 3.89 (1.14) 3.55 (1.30) 4.00 (1.01) 3.74 (1.18) 3.54 (1.44)
N(%) N(%) N(%) N(%) N(%) N(%)
Alcohol and drug use
Drug injection (% yes) 24 (4%) 11 (5%) 4 (1%) 20 (4%) 13 (3%) 6 (3%)
Sexual health risks
Condom off inside (% yes) 31 (5%) 23 (11%) 21 (8%) 19 (4%) 53 (13%) 3 (1%)
HIV/AIDS practice
HIV test (% yes) 349 (56%) 113 (53%) 141 (51%) 293 (60%) 253 (61%) 57 (28%)
Percentage may not add up to 100 due to rounding.
a
Based on Likert scale where higher number means higher frequency.
b
Based on Likert scale where higher number means higher likelihood of using.
c
Based on Likert scale where higher number means higher perceived risk.
1520

Table 5
Multinomial logistic regression model predicting alcohol use in risk situation 1
Response on alcohol intake before
commercial sex vs. no alcohol intake
before commercial sex
No response vs. no alcohol intake before
commercial sex
Predictors β Robust S.E. Odds ratio β Robust S.E. Odds ratio
Individual-level factors
Sociodemographics
Age in years .03 .02 1.03 .00 .02 1.00
Education in years −.02 .05 .98 .18
∗∗
.06 1.19
Weekly wage in pesos .00 .00 1.00 .00
∗
.00 1.00
Lengths of work in months .01 .01 1.00 .01 .01 1.01
Alcohol and drug use
Frequency of drinking alcohol .39
∗∗
.13 1.48 −.20 .13 .82
Frequency of drinking alcohol with clients .08 .09 1.09 −.31
∗∗
.10 .73
Frequency of drug use .54
∗∗
.18 1.72 .62
∗∗
.17 1.86
HIV/AIDS perception and sexual health risks
Frequency of vaginal intercourse .03 .02 1.03 .01 .02 1.01
Likelihood of using condoms 2.85
∗∗
.41 17.29 −1.08
∗
.50 .34
HIV test (reference = no test)
Yes −.45
∗
.23 .64 −.04 .29 .96
AIDS perceived risk −.01 .09 .99 −.17
∗
.09 .84
Contextual-level Factors
Workplace (reference = street worker)
Bar-based worker −.68 .54 .50 −0.70 .54 .50
Non–bar-based worker −1.28
∗
.57 .28 −1.47
∗∗
.72 .23
AIDS education workshop (reference = no workshop)
Yes −.04 .28 .96 −0.30 .41 .74
Wald χ
2
(28)
= 332.35 (p < .01) and pseudo. R
2
= 0.15. Variables with significant Wald tests and odds ratios greater than 1.00 indicate that as the independent
variables increase one unit, the odds of being in certain category increased.
Asterisks indicate that a predictor variable significantly differentiated category membership in the multinomial logistic regression analyses:
∗
p < .05;
∗∗
p < .01.
1521

1522 Chiao et al.
In the second contrast of risk situation 1, FCSWs who did not respond to the
alcohol consumption question were compared with those who did not consume alcohol
before commercial sex (reference group). The education level of FCSWs was significant,
suggesting that higher educated FCSWs were less likely to respond to this question.
FCSWs’ alcohol and drug use significantly differentiated the group membership, such
that FCSWs who used drugs more often but drank alcohol with customers less frequently
were more likely to be in the groups that did not respond to the question. Perceived
AIDS risk was also a significant predictor: FCSWs with lower AIDS awareness were
less likely to respond to the question. Relative to non–bar workers, street workers were
more likely to be in the group that did not have a response as opposed to the reference
group.
Risk Situation 2. The ecological models predicting alcohol use in the second commercial
sex situation were statistically significant: Wald χ
2
(28)
= 309.72 (p < .01). In Table 6, the
first contrast found that sociodemographics significantly differentiated group membership,
such as income and length of work. FCSWs who worked longer were more likely to
have sex with intoxicated customers as opposed to those who did not have sex with
intoxicated customers (reference group). The FCSWs who reported higher rates of drug use
were more likely to be in the groups that had sex with intoxicated customers. HIV/AIDS
perception and practice were also significant between the groups, suggesting that the
FCSWs who did not have an HIV test or those with lower perceived risk of acquiring
HIV were more likely to engage in sex with intoxicated customers compared with the
reference group. Relative to establishment-based (bar or non-bar) workers, street workers
were also more likely to have sex with intoxicated customers as opposed to the reference
group.
In the second contrast for risk situation 2, education level and work duration of FCSWs
was found to be significant, suggesting that higher educated or more experienced FCSWs
were less likely to respond to the alcohol consumption question. FCSWs who reported
drinking with customers were more likely to report having no sex with intoxicated customers
compared with those who did not respond. HIV/AIDS perception and practice were also
significant: The FCSWs with lower perception or those who did not have a HIV test were
less likely to respond to the question as opposed to the group that responded having no sex
with intoxicated customers.
Discussion
Our analyses focused on how alcohol use influenced HIV/STI risk in the context of
commercial sex activities. Currently, there is a lack of information regarding alcohol’s
influence on risky sexual behaviors for FCSWs. Even less is known about the influence of
alcohol use by FCSW customers on unsafe sexual behaviors. Given that the FCSW/customer
dyad is important in this circumstance, FCSWs who are at risk because they have sex with
multiple paying and intoxicated customers confront different behavioral change issues than
women not in the commercial sex trade (Poundstone et al., 2004). The current study built
on our previous work with FCSWs (Morisky et al., 2002c) linking personal and situational
factors as pivotal determinants of sexual risk behaviors.
Overall, this sample of FCSWs displayed a confluence of characteristics suggesting
a significantly elevated risk of HIV/STI transmission. Although most acknowledged an
increased susceptibility to HIV infection, this did not deter many from engaging in unsafe
sexual practices. It is likely that these FCSWs experienced difficulty in implementing safer

Table 6
Multinomial logistic regression model predicting alcohol use in risk situation 2
Response on having sex with intoxicated
customers vs. no commercial sex with
intoxicated customers
No response vs. no commercial sex with
intoxicated customers
Predictors β Robust S.E. Odds ratio β Robust S.E. Odds ratio
Individual-level factors
Sociodemographics
Age in years .03 .02 1.03 −.00 .03 1.00
Education in years −.02 .05 .98 .23
∗∗
.07 1.26
Weekly wage in pesos .00
∗
.00 1.00 .00 .00 1.00
Lengths of work in months .02
∗∗
.01 1.02 .02
∗
.01 1.02
Alcohol and drug use
Frequency of drinking alcohol .20 .15 1.22 −.01 .14 .99
Frequency of drinking alcohol with clients −.14 .09 .87 −.40
∗∗
.10 .67
Frequency of drug use .47
∗
.19 1.61 .28 .22 1.33
HIV/AIDS perception and sexual health risks
Frequency of vaginal intercourse .05 .03 1.05 −.09 .07 .92
Likelihood of using condoms 3.14
∗∗
.40 23.06 −1.41
∗∗
.44 .24
HIV test (reference = no test)
Yes −.57
∗
.25 .56 −1.05
∗∗
.33 .35
AIDS perceived risk −.26
∗∗
.10 .77 −.22
∗
.09 .80
Contextual-level factors
Workplace (ref = street worker)
Bar-based worker −1.49
∗∗
.53 .22 1.02
∗
.41 2.78
Non–bar-based worker −1.25
∗
.61 .29 −.06 .77 .94
AIDS education workshop (reference = no workshop)
Yes −.19 .31 .82 .52 .42 1.68
Wald χ
2
(28)
= 309.72 (p < .01) and pseudo-R
2
= .27.
∗
p < .05;
∗∗
p < .01.
1523

1524 Chiao et al.
sex. About half of the sample indicated that they lacked confidence to propose condom use
to their customers and were reluctant to refuse intercourse if a customer declined to use
a condom. Research has documented that FCSWs tend to acquiesce to customer demands
for noncondom sex, if doing otherwise would translate into loss of financial support (Wee
et al., 2004).
Although risk reduction strategies often emphasize decreasing the number of lifetime
sex partners along with other safer sex strategies, these behavior changes might be especially
difficult for FCSWs, given such changes might well threaten their social and economic
survival. Consequently, the most effective sexual risk reduction interventions may be those
that include customers/clients along with mechanisms at the establishment level to support
condom use. Likewise, HIV interventions might be designed to set establishment policy
discouraging or prohibiting alcohol use by FCSWs and their customers while also enhancing
client awareness of their susceptibility to HIV infection, thus encouraging use of condoms
and other safer sexual methods. Unfortunately, in a transactional sex culture where safe sex
is rare, condom use may not be easily accepted.
Intervention efforts could also be designed for the male customers to encourage more
responsible preventive options (i.e., use of condoms, nonpenetrative sex, body massages to
orgasm). Their success, however, would require “deep-rooted” changes in society’s attitudes
toward sex and masculinity (Foreman, 1998). This approach emerges from broader issues
surrounding gender relations that have come to the forefront in recent years, in addition
to those involving HIV/AIDS. Clearly, HIV prevention interventions must be developed
in a manner acutely sensitive to the needs of each gender to make a significant impact on
behavior change.
Behavioral interventions based on social psychological principles have yielded
strategies that can decrease new HIV and STD infections (O’Leary et al., 2003).
Roger (1983) emphasized the central importance of interpersonal network influences on
individuals in convincing them to adopt new innovations. In the history of our work in the
Philippines, opinion leadership was an important theme in the design and implementation
of intervention strategies at the community level, beginning with the advisory committee
and continuing with key personnel from the City Health Office, SHC, and establishment
managers. This perspective is based on the recognition that HIV transmission is caused by
processes at both the individual and societal levels, all of which affect individual behavior
and rates of transmission (Poundstone et al., 2004). Most intervention approaches are
directed at the individual level, addressing personal issues of knowledge, risk perception,
self-efficacy, or drug abuse (Murphy et al., 2001). The recent Consensus Development
Conference on Interventions to Prevent HIV Risk Behaviors (NIAAA Structural RFA,
2004) called for increased efforts in environmental and structural approaches for HIV
prevention. Our results support this suggestion.
However, it is also important for future HIV risk reduction efforts to incorporate
conceptual models that go beyond the intrapersonal cognitive-behavioral or individualistic
framework and incorporate systemic/contextual mechanisms, emphasizing not only content
but processes. This social ecology of the epidemic has been elaborated (DiClemente and
Wingood, 2000, 2003; Morisky et al., 2002b; Poundstone et al., 2004; Wingood and
DiClemente, 2000). The 2004 annual thematic issue of Epidemiologic Reviews was devoted
to this shift of focus in several topical areas, including HIV/AIDS (Ibrahim, 2004). As
noted by Morisky et al. (2005), because transactional FCSW/client sexual behavior occurs
in an interpersonal/organizational context, organizational norms may indirectly support
or discourage risky behavior. Morisky et al. (2005) stress that individual-oriented change
procedures need to account for social contextual factors to be maximally effective. For

HIV/STI Risk and Alcohol Use Among Sex Workers 1525
example, emphasizing only the cognitive aspects of behavior change, such as belief in
the benefits of condom use, belief in the severity of HIV/AIDS, or beliefs in personal
vulnerability of HIV infection, is not sufficient to put the preventive action into place.
One requires reinforcements outside the individual, such as manager support, peer
reinforcement, and acquisition of specific skills (communication and negotiation of sexual
behaviors). This was demonstrated by intervention outcomes in which changes in social
support and other network factors were associated with reductions in HIV risk behaviors.
Such data suggest that HIV prevention approaches based solely on changes in personal
behavior may have limited impact if systemic/contextual influences (i.e., peer, poverty, and
societal factors) are ignored (Morisky et al., 2005).
Finally, it should be recognized that considerable cultural variation exists within the en-
tertainment establishment. Many factors, including degree of acculturation, socioeconomic
and educational levels, gender, and age, must be considered in judging the appropriateness
of prevention interventions for any given circumstance. Thus it is important to determine
how closely individuals or groups that are targets of prevention interventions adhere to the
values, beliefs, and practices attributed to the Filipino community as a whole. For example,
the educational level is higher among FCSWs employed in the karaoke TV Centers and
educational materials conceptualized and developed by these individuals (such as brochures
and posters) were used in the project. Female bar workers and FCSWs employed in beer
gardens and disco houses had lower educational levels, prompting the use of small group
dynamics to make educational interventions more interpersonal.
Religion plays an important role in the lives of FCSWs, and most claimed to have
a strong belief in God. Aware of the prohibitions imposed on their profession, FCSWs
admitted feeling guilty or sinful, seldom attending mass or church as a consequence.
However, birthdays are extremely important, and almost all indicated that they attend mass
on this day. Consequently, local priests from the communities who had more open views
of the needs of FCSWs and the importance of condom use for preventing HIV/AIDS
were invited to training programs. Their understanding of the dilemma experienced by the
FCSWs allowed them to talk openly on the importance of health, family, and attending
to children’s needs. Their participation had a profound impact on reducing the level of
guilt and dissonance among FCSWs. Additional institutional reinforcements were sought
by forming community partnerships with local health offices, SHCs, and the University of
the Philippines.
In our model of situational and environmental influences on condom use, customer
intoxication was a situational determinant of condom use. Alcohol use among commercial
sex workers represented a personal determinant of condom use. HIV prevention at its best
would attempt to encompass both realms. Our results indicate it is particularly important to
focus on the situational determinants exerting an influence on condom use (i.e., to ensure
that client intoxication does not contribute to HIV risk).
These findings correspond with our previous research showing the importance of
going beyond individual determinants with HIV risk reduction interventions (Morisky
et al., 2002c). In that article we concluded that personal determinants of condom use
(such as condom attitudes) provide important information for constructing any particular
intervention; however, that conclusion does not mean that situational determinants (e.g.,
client intoxication, FCSW drinking) can be ignored as interventions are developed, tested,
and subsequently adopted. The results of the current study provide strong positive support
for organizational-level strategies within FCSW establishments to discourage having
customers who are intoxicated or using alcohol to reduce riskier sexual behaviors, such as
prolonged vaginal or anal sex episodes to reach orgasm. This is what is often described as

1526 Chiao et al.
a structural approach to prevention and would involve training establishment managers
in the effects of alcohol-related increases in the transmission of sexually transmitted
diseases (STDs) and how to communicate with their employees regarding these risks.
We believe the results of this study point to unaddressed risk increases influenced by
alcohol-related factors, stressing the importance of targeting such situations in intervention
activities.
Research conducted in Thailand has already demonstrated the value of using structural
intervention approaches, including a mass condom promotional campaign and a 100%
condom use program instituted in brothels in northern Thailand. This combined approach
resulted in more than a sixfold increase in the percentage of condom use, from 14% to over
90% in a 4-year period, with a concomitant decrease of 85% in male STD cases (Hanenberg
et al., 1994). Similar approaches are being incorporated in the Philippines project, with
educational policy conceptualized as a continuum from meeting regularly with employees
to providing condoms and educational materials, mandating 100% condom use among
employees. Intermediate educational policy activities include encouraging attendance at
the social hygiene clinic, providing an insurance fund for STD prescriptions, promoting
AIDS awareness in the establishment, and making condoms available to customers (Morisky
et al., 2005).
These policies have succeeded because stakeholders (government, managers, commer-
cial sex workers (CSWs), clinics, and other interested groups) have been willing to put aside
their individual goals and focus on the greater good for all. Cooperation between and across
a wide assortment of groups with varying goals, beliefs, and philosophies has been the key
to success. As a result, in nations such as Thailand and the Philippines, there has been
steady progress in the fight to control the spread of HIV/AIDS. Despite alternative cultural
influences, such as the Catholic Church’s choice of abstinence over condom use, these
prevention strategies have continued to be integrated. Given the diverse and sometimes
oppositional normative values that can exist in these countries, self-esteem enhancement
may be especially important in providing further impetus and confidence in the use of
condoms (Nyamathi et al., 1995).
Our baseline analysis provides compelling support for a dual approach to encouraging
safe sex behaviors for women operating as FCSWs in commercial establishments.
It is hypothesized that a combined intervention with FCSWs and managers in such
establishments will result in higher levels of knowledge and awareness as well as more
positive attitudes toward condom use and a higher degree of actual condom use than
interventions targeted at personal or situational factors alone. Further research would be
beneficial to determine specific knowledge gaps regarding risk behaviors, testing patterns,
and HIV incidence and prevalence in FCSWs. This research would be most valuable if it
also included broader contextual factors that influence the lives of FCSWs and their risks
for HIV infection.
Our prior research with this population has underscored that FCSW establishments
are malleable institutions and that a combined intervention with FCSWs and managers
has maximized condom use, reducing unprotected sex and STIs (Morisky et al., 2005).
An important aspect of this research in guiding future policy was to delineate the most
potent variations in implementing a situational/structural intervention with FCSWs. Among
their recommendations for the next frontier of HIV prevention intervention research,
Coates and Collins (1998) state that we “must identify impediments to implementation
of HIV prevention strategies and collect empirical data to repudiate or support those
impediments” (p. 323). This is a crucial criterion for future research because it exposes
untested assumptions often held about groups, institutions, and countries that lead to a
subtle stigmatization in which change is thought to be impossible or too costly.

HIV/STI Risk and Alcohol Use Among Sex Workers 1527
FCSWs and their clients are examples of high-risk subgroups often excluded in
the design of interventions, even when seeking to close the gap between research and
practice. Admittedly, they frequently are included in preliminary focus group studies yet
rarely are enlisted in mutual partnerships with researchers beyond the needs assessment
phase. An important experimental focus of our intervention work in the Philippines has
been to push the boundaries of what is considered possible in the partnership between
these groups and researchers. In practice, this has meant involving FCSWs and clients
in the conceptualization of an intervention, its materials and implementation, and also its
evaluation and interpretation of results (Morisky et al., 2004b, 2005). Traditionally, this has
been called participatory action research; others prefer to define it as peer-driven designs
or “bottom-up” instead of “top-down” approaches. Its basis is not merely an awareness of
social or political stigma, but is an acknowledgement of the intellectual stigmatization that
can pervade academic research institutions. Both types of stigmatization are deadly—not
only to the life possibilities of vulnerable populations, but also to the possibility of the very
innovations hoped for in HIV/AIDS prevention science.
Castro and Farmer (2005) effectively illustrated the life and death consequences of
HIV/AIDS-related stigma, which can emanate from the full spectrum of a country’s
stakeholders. The most notable example in news headlines pertains to the distribution
of antiretroviral medications and concerns about the capacity for strict adherence among
high-risk groups as well as populations in the developing world. These concerns have been
repeatedly dispelled (Chesney, 2000), even in places thoroughly ravaged by the epidemic,
such as Haiti. Castro and Farmer note that people in these countries can recognize what
works the same as other populations and point to the high adherence rates in their programs
in Haiti, which have depended not only on good drugs but also on good services and
linkages. Their critique is that researchers and policymakers must guard against taking
refuge in stigma, and even the study of it, if this distracts from the very real failure to find
workable interventions and system-level solutions for groups and populations unable to
break free of the epidemic. The lesson from our work in the Philippines is that the skills
to be imparted to reduce HIV transmission are not unidirectional, flowing from expert to
population target. Structural interventions must be multidirectional as well as multilevel.
These are the innovations that we are waiting for and that behavioral and social scientists
must find ways of making testable.
Acknowledgments
This research was supported by grant R01-AI33845 from the National Institutes of
Allergy and Infectious Diseases to Donald E. Morisky. We extend appreciation to
co-investigator Teodora Tiglao; research managers Daisy Mejilla and Charlie Mendoza;
and site coordinators Dorcas Romen, Mildred Publico, Angie Casas, and Lolipil Gella.
Glossary
Ecological Model: This model focuses on how social, political, and economic factors as
well as features of the social environment interact with personal characteristics to
determine health.
Female Commercial Sex Worker (FCSW): Women who engaged in commercial sex-related
activity and operating in such venues as beer gardens, bars, nightclubs, karaoke TV
centers, massage parlors, or disco dance establishments, where they have become
known as indirect sex workers. Sometimes referred to as guest relation officers (GROs)
in the Philippines.

1528 Chiao et al.
Situational Alcohol Consumption: Contextual circumstances in which an FCSW and/or her
clients are likely to engage in drinking alcohol. Alcohol consumption, by either one or
both, takes place immediately before the sexual exchange and occurs when he/she is
alone or in the company of the other person.
R
´
ESUM
´
E
Les prostitu
´
ees ont un taux
´
elev
´
e de maladies sexuellement transmissibles (MST) et de SIDA
dans de nombreuses r
´
egions du monde. Cependant, il existe peu d’
´
etudes qui d
´
etaillent la
pr
´
esence de ces maladies
`
a proximit
´
edelafronti
`
ere entre le Mexique et les Etats-Unis,
o
`
u le tourisme sexuel et la prostitution tol
´
er
´
ee parmi les r
´
esidents sont tr
`
es importants.
Le but de cette
´
etude est de comparer les caract
´
eristiques de milieu, les comportements
`
a
risques de contracter le SIDA, la consommation de drogues et la pr
´
esence de MST parmi les
prostitu
´
ees qui ont particip
´
es
`
a une intervention dans deux villes frontali
`
eres. Les donn
´
ees
ont
´
et
´
e recueillies entre Mars 2004 et Septembre 2005. Une comparaison a
´
et
´
e
´
etablie entre
295 prostitu
´
ees de Tijuana et Ciudad (Cd.) Juarez. Parmi les 155 participantes de Tijuana
et les 140 de Ciudad Juarez, la s
´
eropositivit
´
e est de 4,8% et de 4,9% respectivement.
Les prostitu
´
ees de Cd. Juarez sont davantage susceptibles d’
ˆ
etre test
´
ees positives pour une
syphilis active (31,3%) compar
´
ees
`
a celles de Tijuana (11,8%), mais atteignent des r
´
esultats
similaires en ce qui concerne la blennorragie et la chlamydia. Les deux villes montrent
un taux
´
elev
´
e de rapports non prot
´
eg
´
es et de consommation de drogues, cependant les
prostitu
´
ees de Cd. Juarez sont plus susceptibles de consommer la drogue par injection que
celles de Tijuana (75% contre 25%, p < 0.001). La consommation d’h
´
ero
¨
ıne et de coca
¨
ıne
ainsi que la consommation par injection est significativement plus
´
elev
´
ee
`
a Cd. Juarez,
alors que la consommation d’amph
´
etamines l’est
`
a Tijuana. L’injection de vitamines est
courante dans les deux villes. Les analyses de r
´
egression logistiques sugg
`
erent que l’age
inf
´
erieur, l’activit
´
e
`
a Cd. Juarez et la consommation d’h
´
ero
¨
ıne et de coca
¨
ıne sont des
facteurs ind
´
ependants
`
alapr
´
esence de syphilis active, alors qu’
`
a Tijuana, la consommation
d’amph
´
etamines y est fortement associ
´
ee. Les r
´
esultats pr
´
eliminaires semblent montrer que
les profiles
`
a risques concernant le SIDA et les MST parmi les prostitu
´
ees de ces deux villes
frontali
`
eres, n
´
ecessitent des interventions adapt
´
ees aux besoins sp
´
ecifiques de chacune.
RESUMEN
El riesgo VIH/ITS asociado con el uso de alcohol entre trabajadoras comerciales del sexo
(FCSWs) y sus clientes ha sido poco estudiado. Nosotros examinamos esta relaci
´
on entre
1,114 FCSWs (de 15 y 54 a
ˇ
nos de edad) con datos recogidos durante el per
´
ıodo de estudio
inicial hecho en cuatro provincias meridionales de las Filipinas. Fueron examinadas dos
situaciones de riesgo relacionadas al uso de alcohol 1) el uso de alcohol por parte de
las FCSWs antes del sexo y 2) si el cliente fue percibido como intoxicado. Tambi
´
en,
hemos estudiado la influencia de variables socio-demogr
´
aficas sobre comportamientos de
riesgo sexual. M
´
ultiples comportamientos de riesgo sexual fueron observados con m
´
as
frecuencia en las FCSWs si el alcohol fue utilizado antes del sexo comercial o si el episodio
implic
´
o a un cliente percibido como intoxicado. Un total de 42% de las FCSWs que ten
´
ıan
sexo con un cliente intoxicado resultaron positivo en infecciones transmisibles por el sexo
(ITS), significativamente m
´
as que las FCSWs que no ten
´
ıan sexo con un cliente intoxicado
(28%, p < 0.01). Similares significativas diferencias fueron encontradas en las FCSWs
que no hab
´
ıan consumido alcohol antes del sexo y que ten
´
ıan resultados positivos de ITS
(29%) vs. FCSWs que consum
´
ıan alcohol antes del sexo y que ten
´
ıan resultados positivos

HIV/STI Risk and Alcohol Use Among Sex Workers 1529
de ITS (33%; p< 0.01). Nuestro an
´
alisis refuerza la evidencia acumulada en el campo
de que las intervenciones para la reducci
´
on del riesgo sexual necesitan ir m
´
as all
´
adelos
comportamientos individuales de las FCSWs para satisfacer la mir
´
ıada de riesgos como los
observados en este estudio. Estrategias de niveles m
´
ultiples dirigidos a clientes que abusan
substancias y otros factores situacionales y estructurales han probado ser intermediarios
cruciales en otro de nuestro estudio con esta poblaci
´
on. Estas experiencias y sus limitaciones
son discutidas en este estudio.
THE AUTHORS
Chi Chiao, Ph.D., is Assistant Professor in the Depart-
ment of Public Health, National Cheng Kung University,
in Tainan, Taiwan. Her primary research interests are
to investigate the demographic and social processes that
influence sexual health–related behaviors of women. Her
current work is exploring how sexual behaviors among
sex workers are shaped by contextual factors by using
multilevel approach.
Donald E. Morisky, Sc.D., is Professor in the Department
of Community Health Sciences, UCLA School of Public
Health. He is a distinguished fellow in the American
Academy of Health Behavior and the Society for Public
Health Education. His research interests address the psy-
chosocial and behavioral determinants of chronic (high
blood pressure, diabetes) and infectious diseases (tubercu-
losis, HIV/AIDS) and focus on the behavioral construct of
adherence to medical recommendations. He has directed
his research to the design, implementation, and evaluation
of community-based educational interventions using in-
terpersonal and sociostructural/environmental approaches
to behavior modification.
Rhonda Rosenberg, Ph.D., is Research Assistant Profes-
sor in the AIDS Prevention Program in the Stempel School
of Public Health at Florida International University in
Miami, Florida. She has published in screening and
cost/benefit issues of alcoholism prevention in primary
care and in HIV/AIDS prevention and intervention design.
Her research interests are in the affective determinants
of HIV/AIDS risk and the interactive elements of
intervention design. A major interest is the critique
and advancement of structural approaches, including
the emerging research on social and natural capital as
contextual factors in emerging infectious diseases.

1530 Chiao et al.
Kate Ksobiech, Ph.D., is Visiting Assistant Professor at
the J. William and Mary Diederich College of Communi-
cation, Marquette University in Milwaukee, Wisconsin.
Her research interests focus on HIV prevention inter-
ventions, particularly those geared toward injection drug
users. She conducted a meta-analysis of needle exchange
program outcome variables related to risky drug and
sexual behaviors. Ksobiech’s current research efforts are
geared toward the creation of HIV risk reduction mediated
messages for key risk populations.
Robert M. Malow, Ph.D, is Professor and Director
of the AIDS Prevention Program in the Department
of Public Health at Florida International University in
Miami, Florida. As a professor in FIU’s School of
Public Health and the Director of the AIDS Prevention
Program, Dr. Malow has pursued adaptation of effective
interventions for new and culturally diverse populations,
particularly American-born and Caribbean and Latin
American immigrants living in South Florida, all of which
have been the focus of several federally funded studies.
The importance of social networks—relationships with
parents, peers, and other kin—and acculturation were
integral to one such NIH-funded intervention design for
local Haitian-born adolescents. His primary interest has been in developing culturally
sensitive intervention designs and well-controlled studies that will reveal the linkages
necessary to translate research into practice and to make this technology available to
epidemic hot spots, such as the Caribbean region and South Africa.
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