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Short-Term Effect of a Cultural Adaptation of Voluntary Counseling and Testing Among Female Sex Workers in China: A Quasi-Experimental Trial
Global Health Sciences Literature Digest
Published December 6, 2006
Journal Article

Li X, Wang B, Fang X, Zhao R, Stanton B, Hong Y, Dong B, Liu W, Zhou Y, Liang S, Yang H. Short-Term Effect of a Cultural Adaptation of Voluntary Counseling and Testing Among Female Sex Workers in China: A Quasi-Experimental Trial. AIDS Educ Prev 2006 Oct;18(5):406-19.


The Project RESPECT voluntary counseling and testing (VCT) intervention was culturally adapted for female sex workers (FSWs) in Guangxi, China. This study evaluated the impact of the intervention on knowledge, condom use, and incidence of sexually transmitted diseases (STDs).

Study Design

This was a quasi-experimental trial in which FSWs were assigned either to an intervention group receiving counseling, STD testing, and treatment, or to a control group receiving only STD services.


The study was conducted in a suburban area of Nanning, capital of the Guangxi Zhuang Autonomous Region, which has the third-highest number of reported HIV infections in China.


A total of 400 FSWs (200 in each arm) out of a total population of 2000 FSWs were recruited from restaurants, barbershops, and hair-washing rooms in three geographic areas. The mean age of participants was 23.8 years, and 42% were ever married. There were some differences between groups: women in the intervention arm were more likely to be from urban areas (30.7% vs. 15.5%, p<.01) and have had more years of school (mean 6.3 years vs. 5.4 years, p<.05).


The intervention was modeled after the two-session CDC Project RESPECT. It consisted of two counseling sessions accompanied by STD testing and treatment; HIV testing was not performed because of low prevalence. Counseling involved individualized risk assessment, development of a risk-reduction plan, and condom skills training. Approximately one week after initial counseling and STD screening, women returned for a follow-up session and treatment as needed. The control group only received STD services. About half the intervention group was randomized to receive periodic follow-up from health care workers over a six-month period. Project Respect was adapted for FSWs in China by including the following modifications: 1) the first session was lengthened to allow for rapport-building; 2) information on STDs was added to the second session; 3) individualized risk-reduction planning focused on condom negotiation with clients; 4) STD testing, rather than HIV testing, was performed; 5) services were provided at entertainment establishments rather than at clinics.

Primary Outcomes

Primary measures included HIV/STD-related knowledge, condom use efficacy, consistent condom use (use during the last three sexual encounters), and STD infection measured at baseline and six months post-intervention. The STDs evaluated included chlamydia, gonorrhea, syphilis, trichomoniasis, and condyloma accuminata (warts).


One hundred twenty-two women (30%) were lost to follow-up; attrition analysis indicated no significant baseline differences between those retained and those lost to follow-up. After controlling for potential confounders and baseline differences between the groups, those in the intervention group had higher levels of HIV/STD-related knowledge (p<.0001), consistent condom use with clients (52.6% vs. 25.7%, intervention vs control; OR=2.23, 95% CI=1.26-3.96) at six-month follow-up, and significantly lower STD re-infection rates (29% vs. 41%, intervention vs. control; OR=0.44, 95%CI=0.24-0.80).


The authors conclude that the female sex workers in China who received this brief STD counseling-and-testing intervention had improved HIV/STD–related knowledge and condom use, and reduced STDs over a six-month period.

Quality Rating

There is no standard quality-scoring tool for quasi-experimental studies such as this, but the study had several limitations. There were significant baseline differences in condom use, self-efficacy, and knowledge of STDs between intervention and control groups; the attrition rate was high (30%); tests used for diagnosis of chlamydia, gonorrhea, and trichomoniasis were insensitive, and warts cannot be used as an incident STD, since they are not curable.

In Context

The intervention was based on CDC's Project RESPECT, which systematically evaluated the efficacy of different counseling approaches in increasing condom use and decreasing incident STDs.(1) This study demonstrated that, at least in the short run, improved condom use could result from counseling female sex workers. However, analyses of the relationship between self-reported condom use and STDs were not performed. STD infection rates in the control group remained similar over time, suggesting that STD testing and treatment alone may not influence behavior. (2)

Programmatic Implications

This study demonstrates that a brief, two-session VCT program can make short-term improvements in HIV/STD knowledge and condom use among participants, and could be a useful tool in resource-poor settings. However, consistent condom use was only practiced by half of those in the intervention group. This may not be adequate to prevent acquisition of STDs or HIV over time. Longer term and ongoing interventions are probably needed, particularly for sex workers who are usually mobile.


  1. Kamb ML, Fishbein M, Douglas JM Jr, Rhodes F, Rogers J, Bolan G, Zenilman J, Hoxworth T, Malotte CK, Iatesta M, Kent C, Lentz A, Graziano S, Byers RH, Peterman TA. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. Project RESPECT Study Group. JAMA. 1998 Oct 7;280(13):1161-7.
  2. Landis SE, Earp JL, Koch GG. Impact of HIV testing and counseling on subsequent sexual behavior. AIDS Educ Prev. 1992 Spring;4(1):61-70.