Vulnerabilities, Health Needs and Predictors of High-Risk Sexual Behaviour among Female Adolescent Sex Workers in Kunming, China

Adolescent female sex workers (FSWs) who accessed sexually transmitted infection (STI) prevention services, including peer-education-based health promotion and condom access, reported improved sexual behaviour. This is one of the findings of a study that assessed social and behavioural predictors for sexual risk taking and STIs, including HIV, among adolescent FSWs from Kunming, China. In addition, researchers assessed health services needs and use.

One motivation for the research was the observation that adolescent FSWs have often been neglected by HIV/STI strategies and service providers, partly due to the traditional assumption that adolescents should attend school with family support and abstain from sexual intercourse, despite being legally old enough (the legal age for sex in China is 14 years).

A cross-sectional survey was conducted in 2010. Using snowball and convenience sampling, self-identified FSWs aged 15-19 years of age were recruited from 4 urban areas in Kunming. Women consenting to participate were administered a semi-structured questionnaire by trained interviewers identified from local peer-support organisations. Following interview, a gynaecological examination and biological sampling to identify potential STIs were undertaken. A total of 231 eligible and consenting women were recruited, with 201 (87%) completing their interview and accepting STI and HIV testing. Researchers categorised participants as "higher risk" or "lower risk" depending on their primary work setting. Participants at higher risk were those who: walked the streets; worked in bars, small roadside guesthouses/hotels with managers or pimps, foot massage parlours, small saunas/bath rooms, barbershops, karaoke clubs, dancing halls; or were self-employed (soliciting from the internet, a mobile phone, or through a pimp). Those at lower risk worked at VIP (very important person) clubs or big night clubs. Descriptive and multivariable logistic regression analyses were performed.

The study found that adolescent FSWs reported a very low rate of consistent condom use (22.2%). STI prevalence was high overall (30.4%). Half (50.3%) of the respondents had sex while feeling intoxicated at least once in the past week, of whom 56.4% did not use condom protection. Younger age, early sexual debut, being isolated from schools and family, short duration in sex work, and use of illicit drugs were found to be strong predictors for unprotected sex and presence of an STI. Conversely, having access to condom promotion, free HIV counselling and testing, and peer education were associated with less unprotected sex. The majority of women reported a need for additional health knowledge (77.1%), free condom distribution (50.8%), and low-cost STI diagnosis and treatment services (53.7%). Of women who reported STI symptoms in the past year (n=148), about half reported having undertaken self-treatment for STI symptoms (52.4%), and only 25.5% reported seeking care at public health facilities. Compared with the lower-risk group, those working at higher-risk workplaces were significantly less likely to have received peer education and outreach services (62.5% vs 87.5%, p<0.001) and free condoms (59.3% vs 93.3%, p<0.001). While those in higher-risk workplaces were more likely to have received HIV testing (43.8% vs 17.1%, p<0.001), they were less likely to be aware of test results (35.7% vs 72.2%, p=0.009).

Amongst the communication-related points to consider, from the researchers' perspective:

• Governments and policymakers need to consider the influence of legal crackdowns of FSWs, which leads to marginalisation and migration and impedes health workers from providing continuous intervention services.
• Level of education was significantly associated with inconsistent condom use, highlighting the need for integration of sex education into existing primary and secondary schooling. For illiterate adolescent FSWs, existing "youth centres" or "drop-in centres" could be reoriented or reprioritised to serve this specific population with appropriate information.
• This study highlights the need for universal access to youth-friendly counselling, testing, and treatment services. Overall, this information justifies intensified, targeted programmes to increase HIV and STI prevention, treatment, and care activities, particularly at higher-risk venues and among newcomers to the sex work trade.
• There is a need to address the use of illicit drugs and alchohol amongst this population; various studies have shown associations between alcohol use and sexual risk behaviour, and between HIV and STIs, among sex workers.
• Existing sex worker drop-in centres should be reorientated and evaluated to make health services relevant and accessible to young people. This could include recruitment and training of adolescent sex worker peer educators to generate new, innovative, and targeted strategies, as well as efforts to improve confidential, non-judgmental counselling and testing for HIV and affordable STI treatment.

"In summary, current health services, social development and livelihood interventions, and youth programmes are failing to substantially reach these most vulnerable girls in society."