HIV Prevention Campaigns Research Articles

Increased antenatal HIV testing among rural pregnant women: a community-based HIV prevention services program in rural Maharashtra, India

Methods Between August 2006 and April 2007, a communitybased HIV prevention campaign and antenatal clinicintegrated voluntary HIV testing program was initiated in 52 villages in rural Aurangabad district, Maharashtra, India. Questionnaires assessing HIV risk factors and HIV testing utilization were administered to random cross-sectional community samples of 400 adult women who had given birth in the prior 12 months, at Baseline and, after six months, to 400 women each in the PostIntervention and a separate Control community.

Sex, morality and AIDS: The perils of moralistic discourses in HIV prevention campaigns among university students

In 2003, the United States government released $15 billion through the President's Emergency Fund for AIDS Relief (PEPFAR) to support HIV/AIDS interventions in 15 sub-Saharan African countries. This came as a relief to these countries which were struggling to scale up the provision of anti-retroviral treatment. The allocation of a significant proportion of this fund to abstinence-only and be faithful campaigns generated a huge debate amongst researchers and health practitioners in the region. Many questioned PEPFAR's strategy that, besides ignoring contexts of sexual practice, was also seen to be undermining condom promotion. This article examines the relevance of abstinence-only campaigns amongst university students, based on a PhD study conducted at three universities in KwaZulu-Natal, South Africa. The study analysed responses to ABC, and voluntary counselling and testing campaigns on seven campuses. Questionnaires were administered to a total of 1 400 participants at the three universities selected. In-depth interviews were further conducted with 24 students and three HIV/AIDS programme administrators drawn from across the three universities. The study established that abstinence messages were often interpreted through religious or traditional moral codes, rather than the HIV prevention code. While this interpretation generated a positive response amongst students who subscribed to religious or traditional moral values, it also became a basis for rejection of the abstinence strategy by others. The students’ frames of reference with regard to sex, HIV/AIDS, and the HIV prevention notion of abstinence, were ultimately underpinned by their daily experiences within their social groups. It is, therefore, argued that in the context of group dynamics, the categories of sexual activity/nonactivity exist as a continuum of possibilities, hence the abstinence option should be promoted alongside other options, such as being faithful to one partner and using condoms correctly and consistently, rather than as a fixed option.

Mass Media as an HIV-Prevention Strategy: Using Culturally Sensitive Messages to Reduce HIV-Associated Sexual Behavior of At-Risk African American Youth

The evidence base and theoretical frameworks for mass media HIV-prevention campaigns in the United States are not well-developed. We describe an intervention approach using culturally sensitive mass media messages to enhance protective beliefs and behavior of African American adolescents at risk for HIV. This approach exploits the potential that mass media messages have, not only to reach a large segment of the adolescent population and thereby support normative change, but also to engage the most vulnerable segments of this audience to reduce HIV-associated risk behaviors. The results from an ongoing HIV-prevention trial implemented in 2 medium-sized cities in the United States illustrate the effectiveness of this intervention approach.

Hombres Sanos: Exposure and Response to a Social Marketing HIV Prevention Campaign Targeting Heterosexually Identified Latino Men Who Have Sex with Men and Women

This study examined the reach and impact of a social marketing intervention to reduce HIV risk among heterosexually identified (HI) Latino men who have sex with men and women (MSMW). Repeated cross-sectional intercept surveys were conducted in selected community venues during and after the campaign with 1,137 HI Latino men. Of them, 6% were classified as HI Latino MSMW. On average, 85.9% of the heterosexual respondents and 86.8% of the HI MSMW subsample reported exposure to the campaign. Responses to the campaign included having made an appointment for a male health exam that included HIV testing and using condoms. Campaign exposure was significantly associated with HIV testing behavior and intentions and with knowledge of where to get tested. The campaign reached its underserved target audience and stimulated preventive behaviors. Social marketing represents a promising approach for HIV prevention among HI Latinos, in general, and HI Latino MSMW, in particular.

Providing Sex Education to Persons with Learning Disabilities in the Era of HIV/AIDS

Research suggests that disabled people may be at increased risk for HIV infection, yet are excluded from HIV prevention campaigns. Historically people with learning disabilities have been constructed as either being asexual or sexually uninhibited, and sex education considered to be unnecessary or potentially harmful. This article reports on findings of a qualitative study exploring the challenges expressed by participants who provide sex education for persons with learning disabilities, revealing a tension between a human rights discourse and a discourse of restriction of sexual behaviours. Sex education, in the context of HIV/AIDS, may potentially construct sex as dangerous, echoing past constructions of disabled people's sexuality as problematic.

Promoting Safer Sex Through Pleasure: Lessons from 15 countries

The pursuit of pleasure is one of the primary reasons people have sex; and sex is the most common way people contract HIV worldwide. Yet information about how to have (or deliver) pleasurable sex and stay healthy are largely missing from health resources and HIV prevention campaigns. Wendy Knerr and Anne Philpott explore how ‘erotophobia’ in the health and development sectors is hindering effective safer sex promotion, and highlight best practices from The Global Mapping of Pleasure, 2nd Edition, a collection of case studies on pleasure and safer sex communication from countries and contexts around the world.

HIV: Time for the Medical Community to Move Forward

1 December 2008 marks the 20th anniversary of World AIDS Day. The HIV epidemic was first recognised in 1981. Twentyseven years on, there are 33 million people living with HIV worldwide. Last year there were 2.7 million HIV infections and 2 million AIDS-related death. In Asia, an estimated 5 million people are living with HIV as of end 2007.1 In Singapore, the first HIV seropositive case was documented in 1985. Locally, the number of HIV infection is increasing significantly. Last year, there were 422 new cases identified compared to 357 in 2006. As of October 2008, there were 382 diagnosed HIV cases bringing the total close to 4000.2 The revised recommendations issued by the US Centers for Disease Control (CDC) in 2006 focused on increasing routine HIV screening of patients in healthcare settings to achieve earlier detection of HIV infection. Previous CDC and US Preventive Services Task Force guidelines for HIV testing recommended routine counselling and testing for persons at high risk for HIV and for those in acute-care settings in which HIV prevalence was >1%.3 In February 2007, the Ministry of Health (MOH) carried out an unlinked anonymous HIV seroprevalence survey in 5 public hospitals which showed that the prevalence of undiagnosed HIV infection was 0.28%.4 MOH has recently recommended an expanded HIV testing including providerinitiated HIV testing or opt out HIV testing in hospitals in Singapore.5 World Health Organization (WHO) guidelines on opt out HIV testing in healthcare facilities recommend testing for all patients, irrespective of epidemic setting, if their clinical presentation might be related to HIV infection. In addition, testing is recommended as part of medical care for all patients attending health facilities in generalised HIV epidemics (areas where HIV is firmly established in the general population defined if the HIV prevalence in pregnant women is over 1%). WHO guidelines recommend that opt out testing should be offered more selectively in concentrated and low level epidemics. Similar to the US CDC recommendations, WHO recommends that testing must be accompanied by a package of HIV-related prevention, treatment, care and support services. Likewise, efforts should be made to ensure that supportive policies need to be in place to benefit patients as well as minimise potential harms to patients.6 It is essential that there should be a critical review of opt out HIV testing in Singapore. This should include an analysis of patient acceptance, follow-up and linkage to care, any effect on length of stay in the hospital or access to medical care for primary medical condition, additional tests or effects, false positive results, as well as the cost effectiveness of this screening strategy. Hospitals currently drafting their own individual policy should be guided by principles of patient confidentiality, voluntary process, informed consent, adequate training of healthcare personnel involved in HIV testing, counselling as well as linkage to care and treatment. The Health Promotion Board (HPB) has increased its efforts in HIV prevention campaigns and at the time of this paper, MOH is reviewing its policy on subsidy of antiretroviral drugs.7 However, more work needs to be done specifically in relation to HIV stigma and discrimination. HIV-related stigma and discrimination are the greatest barrier that prevents individuals from finding out about their HIV status and therefore preventing them from receiving treatment and care for themselves as well as for their partners. A recent survey conducted by the HPB showed that there are widespread negative attitudes within the general population against people living with HIV. Only half of the 1768 respondents would care for an infected relative, and one fifth would share a meal with someone who has HIV.8 In relation to the healthcare professional’s attitudes and behaviour regarding HIV, there have been 3 published studies and at least 2 unpublished studies done in Singapore.911 The studies were conducted in 1987 and 1996-1997 when the reported number of HIV infections in Singapore was relatively low.2 The results of those studies showed significant stigmatisation and fear of treating people living with HIV. In 2008, a survey of 80 medical and nursing students in their first and second year of training was conducted on their attitudes and beliefs regarding HIV

Stress, Substance Use and Sexual Risk Behaviors Among Primary Care Patients in Cape Town, South Africa

We assessed the relationship between stress, substance use and sexual risk behaviors in a primary care population in Cape Town, South Africa. A random sample of participants (and over-sampled 18-24-year-olds) from 14 of the 49 clinics in Cape Town's public health sector using stratified random sampling (n = 2,618), was selected. We evaluated current hazardous drug and alcohol use and three domains of stressors (Personal Threats, Lacking Basic Needs, and Interpersonal Problems). Several personal threat stressors and an interpersonal problem stressor were related to sexual risk behaviors. With stressors included in the model, hazardous alcohol use, but not hazardous drug use, was related to higher rates of sexual risk behaviors. Our findings suggest a positive screening for hazardous alcohol use should alert providers about possible sexual risk behaviors and vice versa. Additionally, it is important to address a broad scope of social problems and incorporate stress and substance use in HIV prevention campaigns.

Sex work in Mexico: vulnerability of male, travesti, transgender and transsexual sex workers

In Mexico, male sex workers (MSW) and travesti, transgender and transsexual (TTT) sex workers are among the groups most affected by HIV. They suffer from stigma and discrimination, yet are often absent from the design of programmes and HIV prevention campaigns. The objective of this study was to provide an account of the social context in which MSW and TTT sex workers live, by focusing on their sexual identities, sexual practices and vulnerability to HIV. Data collection took place in Mexico City and involved observational work together with 36 in‐depth interviews. Findings reveal a differentiation of vulnerability by sub‐group. In general, vulnerability is influenced by the social context, stigma related to homosexuality and sex work, as well as sex workers' access to scarce social capital and the lack of response in terms of social and health programmes. In order to diminish the vulnerability of MSW and TTT sex workers and reduce their risk of HIV infection, preventive measures are needed which take into account their specific health and social needs, promote meaningful participation and the encourage respect for human rights.

Separation of Spouses due to Travel and Living Apart Raises HIV Risk in Tanzanian Couples

Persons with absent partners may be more vulnerable to risky sexual behavior and therefore HIV. Partner absence can be due to traveling (e.g., family visits or funerals) or to living apart (e.g., work-related or in polygamous marriages). We investigated to what extent partner absence leads to more risky sexual behavior in Tanzanian couples. We compared 95 men and 85 women living apart with 283 men and 331 women living together. Only persons who were still married were included, either living apart or cohabiting at the time of the interview. Subjects were classified into 4 groups: coresidents being either nonmobile or mobile, and people living apart either frequently or infrequently seeing each other. Most people living apart were polygamously married. Men living apart did not report more extramarital sex than coresident men. However, among coresident men, extramarital sex was reported by 35% of those being mobile compared with 15% of those nonmobile. Among women, those living apart reported extramarital sex more often than coresidents (14% vs. 7%), and this was mainly due to women living apart who infrequently saw their husbands. Risky sexual behavior occurs more often in mobile coresident men, and in women living apart infrequently seeing their spouses. These groups are relatively easy to identify and need extra attention in HIV prevention campaigns.

Self–Reported HIV Testing Behaviors among a Sample of Southeast Asians in an Urban Setting in the United States

In light of the abruptness and severity of the HIV/AIDS epidemic in Asia, there has been growing concern in recent years about the HIV/AIDS risks with the steady rate of Asian and Pacific Islander (AAPI) migration to the United States. Little is known, however, about existing HIV risks among non-MSM (men who have sex with men) AAPIs. The purpose of this study was to examine self-reported HIV testing behaviors and their correlates among a sample of 604 Southeast Asians living in a U.S. urban setting. The HIV testing rate among our sample adults is 30.8%, lower than the median HIV testing rate in the U.S. adult population by state, lower than that of the general adult testing rate in the study city, and lower than that of the AAPI MSM population. A low sexually transmitted infection (STI) testing rate as a proxy for low perceived sexual risks and a dearth of HIV knowledge were associated with the low HIV testing rate. Traditional health care access measures, such as availability of medical insurance and a personal doctor, cannot explain the low HIV testing rate in this predominantly immigrant population. Culturally and linguistically appropriate HIV prevention campaigns could increase the awareness of HIV/STI risk in this AAPI population.

A Discursive Approach to Disinhibition Theory: The Normalization of Unsafe Sex Among Gay Men

HIV research and prevention commonly cite disinhibition theory as an explanation for HIV infection among gay men. Analyzing qualitative interview data in which men talk about recreational substance use and their safer sex practices, we interrogate the concept of disinhibition theory from a discursive perspective. From this perspective, we treat talk not as a route or resource to something presumed to lie beyond the talk, but as a form of action designed for its interactional context. We demonstrate how the men normalize unsafe sex through constructions of disinhibition as common and widespread. In doing so, the men manage accountability for their own experiences with foregoing condom use while using substances. Our analysis demonstrates the men's displayed concerns to avoid individualized explanations for having engaged in unprotected sex. This may explain why some gay men may resist HIV prevention campaigns, based on these very individualized explanations.

Coital Bleeding and HIV Risks in South Africa

To the Editor: We were interested to read the report by Kalichman et al. reporting coital bleeding and HIV risks among men and women in Cape Town, South Africa.1 We have previously identified high-risk sexual practices involving bleeding during sex in black South African men and women in Durban in the late 1980s, initially in men with donovanosis (granuloma inguinale) but subsequently in those with other causes of genital ulceration.2,3 While our study focused on sexual intercourse in the presence of genital ulcers, bleeding during sex was reported by a significant proportion. Clearly, HIV prevention campaigns have impacted little on these biologic behavioral factors that must convey a high risk of HIV transmission. We have also recently reported that the proportion of subjects having sex despite ulcers was at a similar high level in 2004 compared with 1988 at the start of the HIV epidemic, again emphasizing the need to change individual behavior to reduce HIV risk at the biological level.4 Clearly, HIV interventions should include some basic biological input. We do not feel that a randomized controlled trial to identify any possible benefits of abstaining from sex when either blood or genital ulcers are present is justified ethically. But perhaps this very lack of randomized controlled trial data has meant that some of the more obvious risk factors for facilitating HIV transmission continue to be overlooked. It must be accepted that acceptance of condoms in South Africa has been limited and that additional HIV prevention messages are long overdue. Educating individuals about the biological transmission dynamics of HIV that apply to them directly might in turn increase condom use when the level of risk of HIV transmission is perceived to be very high.

MTV's “Staying Alive” Global Campaign Promoted Interpersonal Communication about HIV and Positive Beliefs about HIV Prevention

In 2002 MTV launched a global multicomponent HIV prevention campaign, "Staying Alive," reaching over 166 countries worldwide. An evaluation of this campaign focused on three diverse sites: Kathmandu, Nepal; São Paulo, Brazil; and Dakar, Senegal. Data were collected before and after campaign implementation through population-based household surveys. Using linear regression techniques, our evaluation examined the effects of campaign exposure on interpersonal communication about HIV and the effects of campaign exposure and interpersonal communication on beliefs about HIV prevention. We found a consistent positive effect of exposure on interpersonal communication across all sites, though there were differences among sites with regard to whom the respondent talked about HIV. We also found a consistent positive effect of exposure on HIV prevention beliefs across sites when interpersonal communication was simultaneously entered into the model. Finally, in two sites we found a relationship between interpersonal communication and HIV prevention beliefs, controlling for exposure, though again, the effects differed by the type of person the communication was with. These similar findings in three diverse sites provide ecological validity of the findings that "Staying Alive" promoted interpersonal communication and influenced young people's beliefs about HIV prevention in a positive way, evidence for the potential of a global media campaign to have an impact on social norms.

Exposure to MTV's Global HIV Prevention Campaign in Kathmandu, Nepal; São Paulo, Brazil; and Dakar, Senegal

In 2002 MTV aired a global media campaign, "Staying Alive," to promote HIV prevention among 16- to 25-year-olds. Skeptics believed that a global MTV campaign would reach only a small group of elite young people. MTV increased access to its campaign, however, by making all materials "rights free" to third-party (non-MTV) broadcasters. Over 789 million households in over 166 countries had access to some or all of the campaign. To understand the level of actual exposure and the types of young people exposed, data were analyzed from population-based household surveys in three diverse urban areas where a campaign evaluation was conducted: Kathmandu, Nepal; São Paulo, Brazil and Dakar, Senegal. Exposure rates ranged from 12% in Kathmandu, 23% in São Paulo, and 82% in Dakar, reaching an estimated 32,000, 400,000, 220,000 16- to 25-year-olds in each city, respectively. A number of personal, social and economic characteristics found to predict campaign exposure were identified in each site; in general, these were related to economic status and use of "new" media technologies. Though this skew toward more exposure by those with greater resources existed, we found that the campaign audience was in no way composed only of "elite" young people. (For example, although more of those exposed to the campaign had used the Internet compared with those not exposed, this was not the majority of those exposed in most countries.) The possibility of reaching millions of young people through global networks with minimal marginal costs after production, creates a new paradigm for reaching an important segment of young people.

Sexual Risk Behavior and Venues for Meeting Sex Partners: An Intercept Survey of Gay and Bisexual Men in LA and NYC

Understanding the link between venues for meeting sex partners and sexual risk behavior is critical to developing and placing effective sexual health education and HIV prevention services. Non-monogamous gay and bisexual men (n = 886) were surveyed in New York and Los Angeles about the venues that they met recent sex partners: bathhouses, private sex parties, gay bars/clubs, the gym, via public cruising, and the Internet. Bars/clubs, bathhouses, and the Internet were the most endorsed venues for meeting partners. Men having met a majority of their partners (i.e., "preference") via these three venues were compared/contrasted. Those having preference for bars/clubs were dissimilar from men with preference for bathhouses or the Internet on multiple levels (e.g. age, number of sex partners, temptation for unsafe sex). However, these men were proportionally similar in whether they had engaged in a recent episode of unprotected anal intercourse (UAI). Logistic regressions predicting UAI suggested venues might not play a role in differentiating men who had preference for bars/clubs, bathhouses or the Internet. Additional regression analyses utilizing all six venues to predict UAI suggested other person-factors such as identity as a barebacker and temptation for unsafe sex better explain UAI. This research suggests HIV prevention and educational campaigns targeted within venues need also address socio-psychological person-factors in addition to environmental/venue contexts.

Personal Involvement of Young People in HIV Prevention Campaign Messages: The Role of Message Format, Culture, and Gender

To examine young people's reactions to and understanding of HIV prevention messages developed for MTV's global HIV prevention campaign Staying Alive, videotaped campaign materials were shown to focus group discussion (FGD) participants living in urban areas of Brazil, Kenya, Nepal, and Senegal. Responses related to "personal involvement" with the message were identified in the data from these FGDs and were examined in relationship to the emerging message themes, the message format (public service announcements [PSAs] vs. documentary), cultural context (site), and participant gender. Across groups, greater personal involvement (measured by personal connections, emotional reactions, and lessons learned) was found in responses about the documentary format compared to the PSA format. Exceptions were found for specific PSAs that were considered more relevant within specific gender or cultural contexts. Implications of findings for global campaigns were considered.

Women who fall by the roadside: gender, sexual risk and alcohol in rural Uganda

To investigate community perceptions about the different relationship between alcohol consumption and sexual risk-taking for men and women in a high HIV prevalence African setting. Participatory learning and action (PLA) activities were conducted in five rural villages in south-western Uganda in 2002. For each village, discussions and visualization activities over the course of 5 days explored local concepts of fun, drinking alcohol and HIV-related behavioural risks. Twelve focus group discussions (FGDs) investigated emerging themes. Analysis is based on visual outputs, observation notes and focus group transcripts. Attendance at sex-segregated PLA sessions was open to all village residents. FGDs were purposively sampled from drinkers and general population groups. For men, drinking is conducted invariably outside the home, usually at night in bars, emphasizing independence, masculinity and freedom from domestic responsibilities. For women, drinking outside male supervision challenges feminine ideals of domesticity and signifies potential sexual vulnerability. Accepting drinks from men was viewed as signifying assent to sex and refusal could justify men resorting to sexual coercion. Even though drinking is seen to promote sexual risk, HIV prevention campaigns were considered unwelcome in bars. Communities preferred seminars involving drinkers and non-drinkers alike. Public drinking in this community serves as a marker for men willing to exercise privileges of independence (sexual and otherwise) and women willing to defy gender norms (and risk the sexual consequences). The social and symbolic context of drinking suggests why effective HIV prevention around alcohol should not be limited to drinking environments alone.

Does MTV Reach an Appropriate Audience for HIV Prevention Messages? Evidence from MTV Viewership Data in Nepal and Brazil

In response to the growing numbers of young people affected by HIV around the world, MTV (Music TV), the world's largest television network, has aired a global HIV prevention campaign since 1999, expanding it into a multicomponent campaign in 2002. Questions have been raised, however, about whether MTV is an appropriate channel for these messages, given its provocative content and its reach to those at the upper end of the socioeconomic scale. To address questions about who MTV reaches, viewership data were analyzed from baseline surveys conducted as part of an evaluation of the 2002 HIV prevention campaign. The two sites included in this analysis were Kathmandu, Nepal, and São Paulo, Brazil—each with very different cultures and media environments. We found that, in general, heavier viewers of MTV are younger, better educated, and more dependent on their parents, and they have more access to satellite television and the Internet. MTV viewing was associated with positive attitudes toward HIV prevention behaviors (except for abstinence until marriage) but not with premarital sexual activity.

Sex and the Internet: Gay men, risk reduction and serostatus

Access to the Internet has increased dramatically over the past decade as has its use for meeting sexual partners (e‐dating), particularly among gay men. Between June 2002 and January 2004, 128 gay/bisexual men living in London were interviewed one‐to‐one about their experience of e‐dating, sexual risk and HIV prevention. The men were recruited both online (through the Internet) and offline (in clinics and the community); 32 men were HIV‐positive, 59 HIV‐negative, while 13 had never had an HIV test. A key finding was that both identity as well as anonymity are vital to e‐dating. Through a process of online filtering and sero‐sorting, HIV‐positive men are able to meet other positive men for anal sex without condoms. While this does not present a risk of HIV transmission to an uninfected person it does have implications for the potential transmission of other STIs such as syphilis and LGV. Through e‐dating, HIV‐positive gay men can also avoid abuse, discrimination and sexual rejection. Our findings do not support the suggestion that the attraction of e‐dating is that it affords absolute anonymity. We found that the gradual expression of identity is vital for e‐dating among gay men. Internet‐based HIV prevention campaigns need to take account of the different ways in which gay reflexively manage aspects of their identity online Résumé Dans cet article, l'auteur explore le contexte dans lequel la femme risque d'attraper le virus du Sida dans la ville de Chiang Mai en Thaïlande. Il examine le comportement sexuel des hommes et des femmes, leur attitude vis‐à‐vis des métiers du sexe et la perception du risque d'attraper le VIH. Ses conclusions sont tirées des données recueillies au milieu des années 90, au plus fort de l'épidémie. Les hommes et les femmes qui participèrent à cette recherche soulignèrent un certain nombre de thèmes importants. Tout d'abord, certains hommes continuaient à avoir des rapports sexuels non protégés avec des professionnelles du sexe. Deuxièmement, au lieu d'avoir recours aux professionnelles du sexe, les hommes, étant donné leur crainte du Sida, étaient conduits à chercher des partenaires sexuels parmi leurs amies et connaissances car ces personnes étaient censées ne présenter aucun danger par rapport à l'éventuelle transmission du virus. Troisièmement, les femmes qui participèrent à cette recherche ignoraient en grande partie cette extension du réseau sexuel au delà du milieu professionnel du sexe proprement dit. Enfin, la sexualité des femmes était en grande partie méconnue de ceux chargés de promouvoir la politique de santé publique; les participants hommes et femmes n'en tenaient pas compte non plus, ce qui mettait les femmes en danger d'attraper le VIH. Resumen En este artículo examino en qué contexto las mujeres corren el riesgo de contraer VIH valorando la conducta sexual de hombres y mujeres, las actitudes hacia el trabajo sexual y la percepción de riesgo de HIV en la ciudad tailandesa de Chiang Mai. Los resultados se basan en datos recopilados durante mediados de los noventa cuando la epidemia estaba en su punto más álgido. Los hombres y mujeres que participaron en este estudio destacaron una serie de cuestiones importantes. En primer lugar, algunos hombres seguían teniendo sexo arriesgado con las trabajadoras sexuales. En segundo lugar, el miedo a contraer VIH motivaba a los hombres a buscar amigas y conocidas en lugar de trabajadoras sexuales para sus encuentros amorosos porque pensaban que así estaban seguros de no infectarse. En tercer lugar, las mujeres de este estudio desconocían en gran medida la expansión de la red sexual más allá del trabajo sexual. Por último, la sexualidad de las mujeres en general no era reconocida en las respuestas de salud pública o por los participantes masculinos y femeninos, con lo que corrían el riesgo de contraer VIH.