HIV interventions focused on high risk groups, e.g., FSWs, have often targeted individual behavior, with impediments to success frequently including structural factors beyond the scope of the programs [17, 37, 38]. In this study, we have examined the integrated individual, community, structural intervention to HIV/STI prevention, which sought to change those context-specific political, social, legal, and environmental factors that known to affect HIV/STI risk and vulnerability [16, 17], as part of a large-scale Comprehensive AIDS Response, community-based HIV treatment, care, prevention program, in Shandong Province.
This program focused on addressing structural factors using multisectoral collaborative strategies, following individual level intervention and community mobilization of FSWs, worked in collaborative partnership with policy makers, multisectorial stakeholders and civil society (including CBOs/NGOs and FSWs themselves) to address structural barriers, stigma and discrimination facing the FSW community.
The findings of this study revealed the significant lower rate of syphilis, higher score of HIV knowledge, and the higher rates of condom use, HIV testing and the utilization of HIV prevention services in the intervention sites, compared to that in the control sites, which suggested the successes of the integrated individual, community and structural intervention. These findings are consistent with our previous findings  and which also support the finding of other studies in other Asian country that have showed significant increases in condom use, reductions in HIV and STI rates among FSWs [40–42].
The higher score of HIV knowledge among FSWs demonstrated in intervention sites is consistent with our previous study . Our previous study targeted FSWs in the same 6 sites from 2004 to 2008 showed the rate of correct answer of three HIV/AIDS transmission routes increased from 59.36% at baseline in 2004 to 97.21% in 2008, and increased from 32.76% in 2004 to 82.76% in 2008 for correct answer of non-transmission routes. The higher rate of condom use found in the intervention sites is also consistent with our previous report that the proportion of consistent condom use with clients in the last three months significantly increased from 38.75% at baseline in 2004 to 71.67% in 2009 . In addition, the overall low HIV prevalence indicated from surveillance system and lower syphilis prevalence in intervention sites compared to the control sites indicated the integrated individual level intervention, community mobilization and structural intervention prevention program with multi-sectoral cooperation and strong societal participation made the difference.
Although the progress was evidenced by the increase in condom use in intervention sites compared with control sites, the rates of condom use among FSWs are still low. Condom use has been proven to effectively prevention the transmission and control the epidemic among FSWs, but the coverage of condom is the key [27, 43–47]. The Asian Epidemic Model predicts that a high rate of condom use (>85%) among FSWs is required to control the HIV epidemic [27, 43, 46]. Data also showed high levels of condom use among FSWs and their clients in countries such as Benin, Thailand and Cambodia are likely to have slowed the epidemic [10, 48]. Shandong with 140 counties is the second most populous province in China. The study indicated that the progress on HIV/STD intervention has been made uneven among counties across the province and within counties. This study also showed two-thirds of them had not previously tested for HIV. The relative low condom use and utilization of HIV-related prevention services in both intervention and control sites highlighted the needs of continued effort in scaling up the care, treatment and prevention activities.
Commercial sex in China is illegal. FSWs are often blamed for the breakdown of the traditional family, epidemics of STIs and HIV/AIDS, and escalating crime [22, 24]. Therefore, stigma and discrimination and other potential barriers might have prevented FSWs seeking VCT or other HIV prevention and care services for fear of discrimination, fear of disclosure of commercial sex activities, low of confidentiality [24, 49], and fear of the punishment of the illegal commercial sex. Study also showed stigma and discrimination, site atmosphere, links with other services, quality of the staff, and convenience were important factors for FSWs actively receiving HIV testing and HIV-related services [50, 51]. Hence, the stigma and discrimination reduction effort with multi-sectoral cooperation and strong societal participation, years of efforts of intervention service promotion, well trained health professionals, peer education, condom distribution and promotion, should be a critical part of the large scale Comprehensive AIDS Response program to contain STIs and HIV/AIDS epidemic among FSWs.
Trainings on discrimination and stigma have been a part of China’s response to HIV for many years, but there remains a high degree of ignorance, misinformation and stigma surrounding the virus . This is slowly changing, and a growing number of PLHIV are now willing, given the proper support, to reveal their status. It is therefore now possible to adjust the strategy and adopt a new method: engaging HIV infected individuals and encouraging them to participate in all aspects of anti-stigma campaigns. The fundamental logic behind this activity is that PLHIV involvement in anti-stigma activities can greatly improve their effectiveness . The stigmatization of HIV-infected people and many of the sub-populations who are most vulnerable to infection, and the discrimination that results from it, act as constraints on the delivery of prevention and health care services and damage the lives of those infected with or affected by HIV/AIDS. A high degree of stigma also helps to keep people ignorant about the disease, which increases their own risk of becoming infected. Tackling discrimination and stigma was therefore an integral part of this integrated intervention. Efforts were informed by international best practices related to reducing stigma and discrimination and advocacy for the rights of PLHIV and other key affected populations. By reducing stigma and discrimination in all settings and particularly in health care settings, it is expected that more of the people who are infected or are most at risk of infection will be encouraged to access prevention services, treatment, care and support. Although no data were collected in evaluating the changes of stigma and discriminatory practices and attitudes, the efforts in reducing stigma and discrimination likely affected the behavior change towards eliminating attitudes and practices that act as barriers to ensuring the rights of PLHIV and key affected populations and their access to services and entitlements. The higher rates of HIV testing and the utilization of HIV prevention services in intervention sites, compared to the control sites, which may reflect certain success of stigma and discrimination reduction effort.
The effective method of promoting multisectoral participation in HIV/AIDS prevention, care and treatment is to ensure that each sector has its own responsibilities, in line with its respective strengths and comparative advantages, under an agreed HIV/AIDS action framework. The involvement of community such as CBOs, grassroots NGOs and organizations representing PLHIV and FSWs, is encouraged by the Global Fund AIDS Program, has played a consistently important role in increasing capacity building and technical support to civil society. Effective multisectorial cooperation and improved community participation in the six intervention sites ensured the successful implementation of the community-based HIV treatment, care and prevention program.
Strengths of this study include its estimation of the size of the targeted population and mapping strategy. Efforts on investigating the venue and preliminary estimates in each establishment strengthen the mapping strategy and targeted population size estimation to reduce selection bias. Our study subjects may represent a wider spectrum of FSWs in Shandong. The socio-demographic and behavioral factors identified in our study are informative, giving us a stronger grasp of Shandong’s current HIV epidemic and risk behavior and the use of prevention services among FSWs. We also recognized the limitations of this study. Selection bias existed in this study. Non-response information was not collected. The questionnaire data relying on retrospective self-reports was subject to recall bias. Sensitivity of sexually-related questions could lead to reporting bias. The cross-sectional research design precludes identification of causal relationships. No baseline survey conducted among control sites could be another limitation of the study. This study also served as a behavior surveillance survey, which was conducted with careful planning, implementation, and quality control. In spite of these limitations, we believe that this study provide invaluable information to guide the ongoing comprehensive community-based treatment, care, prevention intervention program among this group.