Elsevier

The Lancet

Volume 355, Issue 9221, 17 June 2000, Pages 2101-2105
The Lancet

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Promotion of condom use in a high-risk setting in Nicaragua: a randomised controlled trial

https://doi.org/10.1016/S0140-6736(00)02376-XGet rights and content

Summary

Background

In Latin America, motels rent rooms for commercial and non-commercial sex. We investigated the impact of providing health-education material and condoms on condom use in Managua, Nicaragua.

Methods

In a randomised controlled trial, in 19 motels, we gave condoms on request, made them available in rooms, or gave condoms directly to couples, with and without the presence of health-education material in the rooms. In a factorial design we assessed condom use directly by searching the rooms after couples had left.

Findings

11 motels were used mainly by sex workers and their clients and eight mainly for non-commercial sex. 6463 couples attended the motels in 24 days. On 3106 (48·0%) occasions, at least one used condom was retrieved. Condom use was more frequent for commercial sex than for non-commercial sex (60·5 vs 20·2%). The presence of health-education material lowered the frequency of condom use for commercial sex (odds ratio 0·89 [95% CI 0·84–0·94]) and had no effect on use for non-commercial sex (1·03 [0·97–1·08]). Condom use increased for commercial (1·31 [1·09–1·75]) and noncommercial sex (1·81 (1·14–2·81) if condoms were available in rooms. Directly handing condoms to couples was similarly effective for commercial sex but less effective for non-commercial sex (1·32 [1·03–1·61] vs 1·52 [1·01–2·38]).

Interpretation

In Latin America, motels are key locations for promoting the use of condoms. Making condoms available in rooms is the most effective strategy to increase condom use, whereas use of health-education material was ineffective. These findings have important implications for HIV-prevention policies.

Introduction

More than 30 million people are estimated to have HIV-1 infection worldwide, and 16 000 new infections, mostly acquired heterosexually, are estimated to occur each day.1 Most HIV-1-infected people live in less-developed countries, mainly in sub-Saharan Africa and southeast Asia. In the absence of an effective vaccine, behavioural change is at the centre of HIV/AIDS prevention, including the promotion of condom use.1, 2, 3, 4 Little, however, is known about the effectiveness of different strategies intended to encourage and facilitate protective behaviours among people at risk of infection.

Randomised trials are recommended as the primary strategy for assessment of programme effectiveness,5 but are rare. Among 1184 abstracts submitted with the keywords “behavioural interventions” to the 12th World AIDS Conference in Geneva in 1998, only 30 (2·5%) described randomised controlled trials. There are practical and political difficulties with such trials, and studies frequently require substantial investment of time, expertise, and funding. These factors have probably contributed to the generally low quality of evaluation research in the field of HIV and AIDS prevention.6, 7, 8 Another factor is the “urge to do something”, coupled with strong beliefs that interventions will work, which is understandably widespread among public-health advocates, AIDS activists, and their allies.9 The production and distribution of leaflets and posters, and the distribution of condoms to people perceived to be at high risk of acquiring HIV-1 infection, has been a regular component of prevention activities.

Nicaragua is a country with rapidly rising HIV-1-infection rates1, 10 and the prevalence of sexually transmitted infections is high.10, 11 In Nicaragua and elsewhere in Latin America, motels, boarding houses and hotels rent rooms for short times for discreet commercial and non-commercial sex. These establishments are called moteles in Nicaragua (motels in this paper). We did a randomised controlled trial with a factorial design of condom promotion by use of health-education leaflets and posters and different strategies of condom provision in motels in Nicaragua's capital, Managua, to find out whether these factors could increase condom use.

Section snippets

Study area and selection of motels

We did this study, preceded by a pilot study in 1990,12 in Managua's district IV. This district is in central Managua and has about 200 000 residents who are mainly from lower socioeconomic strata. The district includes Managua's largest street market (Mercado Oriental), from where many sex workers operate. We made a list of all the motels in the study area based on registers of motels from the police, the municipality, and the health centre that serves the area. We also did a street-to-street

Results

Seven (19·4%) motel owners refused to be interviewed and nine (25·0%) were interviewed but declined to participate in the study. 20 motels were therefore included; 12 were used mainly for commercial sex and eight for non-commercial sex. Condom use for 6507 couples was recorded on 473 motel-days between July 31 and October 4, 1997. One motel closed down during the study period and the 44 (0·68% of total) couples recorded on 17 (3·6% of total) days at this motel were excluded from further

Discussion

Evaluation research should provide information on the development of programmes aiming to increase condom use. The choice of an adequate outcome is central to the design. New HIV-1 infection is clearly the most informative outcome in assessment of any prevention programme for HIV and AIDS. Although studies have been done with incidence of HIV-1 or other sexually transmitted infections as the outcome,15, 16 sample-size constraints in low-risk populations and ethical issues in high-risk groups

References (26)

  • SO Aral et al.

    Do we know the effectiveness of behavioural interventions?

    Lancet

    (1998)
  • GJ Hart

    The evaluation of behavioural interventions for gay men: obstacles to evidence-based prevention

    Int J STD AIDS

    (1996)
  • N Low et al.

    AIDS in Nicaragua: epidemiological, political and sociocultural perspectives

    Int J Health Serv

    (1993)
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