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The UALE Project: Decline in the incidence of HIV and sexually transmitted infections and increase in the use of condoms among sex workers in Guatemala
Global Health Sciences Literature Digest
Published October 5, 2009
Journal Article

Sabidó M, Giardina F, Hernández G, et al. The UALE Project: Decline in the incidence of HIV and sexually transmitted infections and increase in the use of condoms among sex workers in Guatemala. JAIDS 2009 May;51(Suppl 1):S35-S41.


To assess the impact of a multilevel sexually transmitted infection (STI) and HIV prevention and treatment intervention on the incidence of STIs and HIV, the use of condoms, and HIV knowledge among sex workers (SWs) in Guatemala

Study Design

This was an open-enrollment cohort study looking at patients who attended STI clinics from March 2005 to September 2008. Patients were asked to return for 6-month follow-up visits.


Three STI clinics integrated into the primary health care system in three municipalities in the province of Escuintla, Guatemala


The cohort totaled 1,554 women who came into the STI clinics, identified themselves as SWs, and provided informed consent. Seventeen percent were indigenous, 57% were illiterate, 37% were migrants from surrounding countries, 5% were married, 83% had at least one child, and 60% were SWs for <1 year. The average age was 29 years. Thirty-four percent had regular clients and 31% had regular partners.


The SWs were invited to come to the clinics every 6 months. Each visit included taking a detailed medical history to assess the risk of STIs and performing a clinical examination. A speculum examination was performed during which genital swabs were taken for laboratory screening for STIs. In a structured interview a health educator provided HIV counseling and recorded data on sociodemographic characteristics, sexual behavior, and HIV knowledge. Additionally, venous blood was drawn for syphilis and HIV testing. The participants were asked to come to the clinic after 7 days for a re-examination where they received post-test counseling and treatment for laboratory-confirmed infections. Any genital tract infection identified was treated according to national guidelines. HIV-infected women were referred to the appropriate hospitals

Primary Outcomes

The primary outcomes were STI and HIV incidence.


At baseline, 91% of the SWs reported using a condom with new clients during their last sexual encounter, 92% reported using a condom with regular clients, and 26% reported using a condom with a regular partner. The proportion of participants who reported consistent condom use with both new and regular clients in the last 6 months was initially high (at baseline) and increased significantly over follow-up visits (P<0.012 and P<0.035, respectively). The proportion of women who reported condom use as an HIV preventive measure significantly increased from the baseline visit through the third follow-up visit (P<0.008), as did the proportion of women who reported knowing about mother-to-child transmission of HIV (P<0.007). The incidence of all STIs significantly declined over each follow-up visit, with the exception of syphilis. The repeat analyses based on the 293 women who presented for at least three follow-up visits also showed a significant decline in all STIs, excluding syphilis. The incidence of HIV significantly dropped from 1.85 per 100 person-years in 2005 to 0.42 per 100 person-years in 2008 (P<0.05).


The authors conclude that the counseling and clinical follow-up intervention was feasible and effective in reducing STI and HIV incidence and in increasing HIV-related knowledge and condom use with clients.

Quality Rating

Based on the Newcastle-Ottawa Quality Assessment scale this study is of adequate quality, although with some limitations. It appears that there was no mechanism to reach individuals who were considered lost to follow-up. There may have been greater loss to follow-up in subgroups at greater HIV risk; therefore, there might have been a healthier cohort at later stages, and inferences about reductions in STI and HIV incidence may be confounded by high loss to follow-up. Another limitation is that the study did not reach out to community-based SWs who work outside brothel-based settings. In addition, there may have been recall bias or self-reporting bias with regards to the sexual health questions.

In Context

The UALE Project is one of the few comprehensive interventions for the prevention and control of STIs and HIV among SWs in Central America that includes clinical, behavioral, and structural components. Similar to other studies, this study found that the control of STIs can have a potential protective effect on HIV incidence.(1,2,3,4) Over the duration of the study period, the incidence of HIV significantly dropped as occurred in other cohort studies conducted among high-risk groups (1,4,5,6) Other studies also have shown a significant reduction in STI incidence, excluding syphilis.(2)

Programmatic implications

This study not only showed that the intervention significantly reduced STI and HIV incidence in the short-term among SWs, it also showed that such an intervention was feasible and well accepted by local health authorities, health care professionals, SWs, and owners of commercial sex establishments. To understand whether this type of intervention has a lasting effect on HIV and STI incidence, a longer study period is required. In addition, new studies need to focus on reducing loss to follow-up for a stronger cohort of individuals over time.


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  2. Ma S, Dukers NH, van den Hoek A, et al. Decreasing STD incidence and increasing condom use among Chinese sex workers following a short term intervention: a prospective cohort study. Sex Transm Infect 2002;78:110-14.
  3. Sanchez J, Campos PE, Courtois B, et al. Prevention of sexually transmitted diseases (STDs) in female sex workers: prospective evaluation of condom promotion and strengthened STD services. Sex Transm Dis 2003;30:273-9.
  4. Ngugi EN, Wilson D, Sebstad J, et al. Focused peer-mediated educational programs among female sex workers to reduce sexually transmitted disease and human immunodeficiency virus transmission in Kenya and Zimbabwe. J Infect Dis 1996;174(Suppl 2):S240-S247.
  5. Grosskurth H, Mosha F, Todd J, et al. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomised controlled trial. Lancet 1995;346:530-6.
  6. Riedner G, Hoffmann O, Rusizoka M, et al. Decline in sexually transmitted infection prevalence and HIV incidence in female barworkers attending prevention and care services in Mbeya Region, Tanzania. AIDS 2006;20:609-15.