Gatekeeper characteristics and consistent condom use among female sex workers in China: A multi-level analysis

Background & Objectives: Environmental or structural factors have received increasing attention in HIV/STI prevention. Despite the persistent association of both perceived gatekeeper support and environmental support and condom use among establishment-based female sex workers (FSWs), the clustering inherent in the data (FSWs clustered within gatekeeper/s of one establishment) have not been accounted to date. We used multi-level analysis to examine features of gatekeepers and individual correlates of consistent condom use among FSWs.

Methods: We conducted a cross-sectional study to investigate consistent condom use with clients among 333 FSWs recruited from 30 entertainment establishments in southwest China in 2004, with a minimum of 5 FSWs per establishment. The GLIMMIX macro in SAS was used in models containing random effects and binary outcomes.

Results: About 13% of women had consistently used condoms with clients. The intra-class correlation coefficient indicated 22.7% of the variance in condom use could be attributed to gatekeeper and establishment level. Women's education and perceived gatekeeper support for condom use were positively associated with consistent condom use independent of other individual characteristics (p<0.05). Significant risk factors included alcohol use (i.e., being intoxicated with alcohol at least once last month, ever using alcohol before sex with clients), being ethnic minority, and more months entering sex work (p<0.05).

Conclusions: Both perceived gatekeeper support and other individual compositional effects are associated with consistent condom use with clients among FSWs in China. The results imply that combined interventions to intervene both gatekeepers and individual FSW may effectively promote consistent condom use.