EXUALLY TRANSMITTED INFECTION

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2 AND H IV S S S P P S URVEY URVEILLANCE EXUALLY TRANSMITTED INFECTION ERIODIC REVALENCE URVEY LAO PEOPLE'S DEMOCRATIC REPUBLIC, 2001 Funded by the United States Agency for International Development (USAID) through FHI's Implementing AIDS Prevention and Care (IMPACT) Project, Cooperative Agreement HRN-A c 2003 Family Health International (FHI). All rights reserved. this book may be freely reviewed, quoted, reproduced or translated, in full or in part, provided the source is acknowledged. This report may not be sold or used in conjunction with commercial purposes. ISBN

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4 T TABLE OF CONTENTS ABBREVIATIONS EXECUTIVE SUMMARY Introduction 1 Background 1 Methodology 2 Results 2 Conclusions and Recommendations 4 INTRODUCTION 5 BACKGROUND 7 METHODOLOGY Sampling 9 Fieldwork and Data Collection 10 Laboratory Testing 11 Data Analysis 12 Ethical Approval 12 RESULTS Final Participation Numbers and Response Rates 13 Demographic Characteristics 14 Sexual Activity and Condom Use 16 Genito-Urinary Symptoms 21 Laboratory Results 24 Data Variability Between Teams 27 DISCUSSION Behavioral Data 29 Genito-Urinary Symptoms 31 Laboratory Results 32 Relationship Between Behavioral 32 and Laboratory Data SUMMARY / CONCLUSIONS 35 RECOMMENDATIONS 37 REFERENCES 39

5 A ABBREVIATIONS AIDS BSS CHASPPAR CLE CT ELISA FHI FVU GC HIV HSS IEC NCCA PA PCCA PCR PDR RPR SPPS STD STI TPHA Acquired immune deficiency syndrome Behavioral surveillance survey Control of HIV/AIDS/STD Partnership Project in the Asian Region Center for Laboratory and Epidemiology Chlamydia trachomatis Enzyme linked immunosorbant assay Family Health International First void urine Gonococcus (Neisseria gonorrheae) Human immuno-deficiency virus HIV sentinel sero-surveillance Information, education, communication National Committee for the Control of AIDS Particle Agglutination test Provincial Committee for the Control of AIDS Polymerase Chain Reaction People s Democratic Republic Rapid Plasma Reagin screening test for syphilis STI periodic prevalence survey Sexually transmitted disease Sexually transmitted infection Treponema pallidum haemagglutination assay

6 E EXECUTIVE SUMMARY Introduction Lao PDR stands in a unique position among Asian countries confronting HIV. A landlinked country, it shares borders with countries with significant epidemics, particularly Thailand, Cambodia, and Myanmar. Yet the limited data available show very low HIV prevalence within Lao PDR. Previously, no coordinated strategy for monitoring HIV and sexually transmitted infection (STI) prevalence and high-risk behaviors existed in Lao PDR. In 1997, the government attempted to institute an HIV Sentinel Surveillance (HSS) program to provide a clear picture of HIV seroprevalence in the country, though no national study was completed. Smaller studies among specific target populations had been conducted, however a large-scale study of HIV and STI prevalence and the behaviors facilitating their spread was still lacking. On the recommendation of the National Committee for the Control of AIDS Bureau (NCCA), and partner agencies, a second generation HIV surveillance system was established in 1999 to study HIV-related risk behaviors and the prevalence of HIV and STIs. The second generation surveillance was made up of two components that will be repeated to allow the measure of trends over time. In , a Behavioral Surveillance Survey (BSS) was conducted in five provinces and measured HIV risk factors among seven high risk populations. The data collected in this component is documented in a separate report. The second step in achieving an integrated surveillance system was the implementation of the HIV Sentinel Surveillance (HSS) and STI Periodic Prevalence Survey (SPPS) in The findings of this survey are documented in the following report. The data was collected using the same methodology as the BSS rendering both surveys comparable. The surveillance was coordinated by the NCCA with Family Health International (FHI), Lao PDR HIV/AIDS Trust, World Health Organization (WHO), Control of HIV/AIDS/STD Partnership Project in the Asia Region (CHASSPAR), and Ministry of Health-European Union STD Project (MOH-EU STD Project). Background Target populations were selected based on documented HIV risk activity, accessibility, and their inclusion in the BSS. Surveillance locations were chosen based on population density, levels of HIV case reporting, the existence of significant numbers of the target populations, and the need to include demographically representative regions nationwide. Executive Summary 1

7 The target populations included service women (SW), female factory workers (FFWs) and long distance truck drivers (LDTDs). Service women were defined as any woman who worked in a small drink shop, nightclub or guesthouse and had direct contact with patrons. In addition to serving food or beer, or providing conversation to customers, some SW sold sex. SW were not screened to determine whether they sold sex before enrollment in the survey. Female factory workers worked in garment factories in Vientiane Municipality and lived in dormitories either on the factory grounds or nearby. Male long distance truck drivers sampled included drivers and drivers assistants who drove routes both within the country and internationally. HSS-SPPS surveillance provinces were Luang Prabang in the north, Vientiane Municipality in the central region, and Savannakhet and Champasak in the south. Data collection was conducted over a six week period from February to April Interview teams obtained verbal informed consent from all participants, and all data collected was anonymous. They then administered a questionnaire and collected blood and urine specimens. After the data collection, the team leader provided educational materials, condoms, a small gift consisting of a first aid kit, referral for STI and HIV testing, and treatment for those participants reporting current STI symptoms. Serum samples were analyzed for HIV antibodies and syphilis at the local provincial laboratories and confirmatory testing was conduced at the Center for Laboratory and Epidemiology, Vientiane Municipality. Urine was analyzed for Chlamydia trachomatis and Neisseria gonorrheae using Roche manual microplate Amplicor polymerase chain reaction (PCR), at Bangrak Hospital Laboratory, Division of Venereal Diseases of the Ministry of Pub lic Health, Thailand, and quality control was conducted at the CDC/HIV/AIDS Collaboration Laboratory in Bangkok. Methodology Results A detailed geographic mapping exercise of the sub-populations was carried out in all sites to update the BSS mapping and was done by the NCCA and Provincial Committee for the Control of AIDS (PCCA) staff. Female factory workers were surveyed in Vientiane Municipality using a two-stage cluster sampling methodology (PPS) with a sample size of 300. Service women were selected in Vientiane Municipality using PPS, and Savannakhet and Luang Prabang using a takeall approach with a total sample of 840. Long distance truck drivers were surveyed at all major truck stops in Vientiane Municipality and Champasak. All truck drivers were selected within a given time frame and a total of 300 were included in the survey. Female factory workers were the youngest population, with an average age of 20.3 years. The majority of FFWs (98.7%) were unmarried and not living with a partner. A low proportion of FFWs reported STI symptoms currently (3.5%) or in the past year (5.7%). No HIV or syphilis was found among this population. The prevalence of chlamydial infection in FFWs was 6.6% and gonococcal infection was 0.4%. Service women had an average age of 21.7 years, and a majority (83%) were unmarried and not living with a partner. Among SW, 92.4% reported they had ever had sex, and 65.5% reported selling sex in the past year. Almost 2 HSS and SPPS : Lao People s Democratic Republic, 2001

8 half reported sex with a non-regular partner in the past year, and 19% had a regular partner. The mean number of sexual partners in the past year was 13.7 with statistically significant differences between provinces. Service women in Savannakhet had an average of 36.1 partners in the past year, compared with 8.6 and 3.2 partners in Vientiane Municipality and Luang Prabang respectively (p<0.05). Service women who reported selling sex had an average of 19.5 clients in the past 12 months. Service women who sold sex for money in Luang Prabang and Vientiane Municipality averaged 3.1 and 12.8 clients respectively in the past year, compared to 45.8 clients in the past year among SW in Savannakhet (p<0.05). Government workers (43.1%) and businessmen (34.5%) were the most common occupation groups of their last three clients. Other occupations reported included soldiers or policemen (5.9%) and truck or taxi drivers (1.4%). Reported condom use with a client at last sex was 90.3% and consistent condom use in the past month was 60.1%. Luang Prabang SW reported significantly lower rates of consistent condom use in last month (49.3%) than SW in Vientiane Municipality (60.0%) and Savannakhet (71.4%) (p<0.05). The median price for sex was 200,000 kip (or about USD 22). Among SW, 20.8% reported a current STI symptom and 38.9% had a symptom in the past year. The prevalence of HIV among all SW was 0.9%, and was 1.1% among the SW who reported selling sex. Syphilis prevalence among all SW was 0.2%. The prevalence of chlamydia was 32.0% and of gonococcal infection was 13.9%. Either chlamydial or gonococcal infection was detected in 37.6% of SW. Significant differences were found in chlamydial infection among the provinces with less than a quarter (23.3%, p<0.05) of SW infected with chlamydia in Savannakhet, compared to 31.9% in Luang Prabang and 34.8% in Vientiane Municipality. Long distance truck drivers had an average age of 34.8 years, and 80% were married and living with their spouse. A majority (75%) had stayed overnight away from their home in the past three months and reported spending an average of 9.4 days each month away from home. Over half of the drivers had ever driven to another country, with 42% doing so at least once per week. Almost all LDTDs reported ever having sex (96.7%). Among LDTDs, a majority reported having a regular partner (81.7%) in the past 12 months, and 23% reported a non-regular partner. No truck drivers reported having sex with a man in the past year. Sex with a commercial partner in the past 12 months was reported by 40.7% of the population, and among those with a commercial partner 54.9% had sex with three or more commercial partners in the past 12 months. Paying for sex was more commonly reported by LDTDs in Vientiane Municipality (50.0%) than Champasak (31.3). Among LDTDs with a commercial partner, 44.3% reported consistent condom use and 59% used a condom the last time they paid for sex. The most common place that the last commercial partner was found was a small drink shop (59.0%), followed by a nightclub (13.1%), on the street (9.8%) and a guesthouse (8.2%). The median price of the last occasion of commercial sex was 50,000 Kip. Few of the LDTDs reported a current STI symptom and 11.0% had a symptom in the past year. No HIV was detected in the subpopulation. The prevalence of syphilis was 1.3%, with Champasak accounting for 2.0% and Vientiane Municipality 0.7% of infections. Chlamydial prevalence was 9.3% (12% in Vientiane Municipality and 6.7% in Champasak), and gonococcal prevalence was 1.3%, with no difference between provinces. Executive Summary 3

9 Conclusions and Recommendations Although HIV has entered the Lao population, prevalence remains low in all groups surveyed, and positive syphilis serology and self-reported genital ulcer disease were rare. Despite these encouraging results, almost half of the service women were infected chlamydia and/or gonorrhea, and long distance truck drivers had high rates of chlamydial and gonococcal infection and genito-urinary symptoms. Though chlamydia and gonococcal infection were low among female factory workers, the prevalence was significant given the relative sexual naivety of this population. Lao PDR still has a window of opportunity to maintain low HIV prevalence by institutionalizing substantial targeted HIV and STI intervention programs including improved STI management and interventions designed to fit the differing geographical situations. Monitoring HIV, STI and behavioral trends should continue through the behavioral and biological surveillance and by strengthening the passive HIV surveillance system. An effort should be made to include other risk groups in the surveillance system, particularly migrants working in Thailand, and to collect data on sexual risk taking behavior among sub-populations who travel to other countries. Qualitative research should be conducted to follow-up on the findings among service women, particularly to validate high levels of condom use, to gain more specific demographic information on their clients, and to explore whether other service women exist who charge lower fees. 4 HSS and SPPS : Lao People s Democratic Republic, 2001

10 INTRODUCTION Lao PDR stands in a unique position among Asian countries confronting HIV. A landlinked country with a population of 4.8 million, it shares borders with countries with significant HIV epidemics, especially Thailand, Cambodia, and Myanmar. Yet the limited data available show very low HIV prevalence within Laos. As trade and new land routes open up into neighboring countries, the potential of HIV being introduced through migrating and mobile populations in Lao PDR is increasing. Communities previously isolated from both the HIV virus and intervention efforts would be vulnerable to its spread. The National Committee for the Control of AIDS Bureau in Laos (NCCA) and its partnering governmental and non-governmental organizations recognize the susceptibility and have taken steps to increase both surveillance and intervention programs in an attempt to avert an HIV/AIDS epidemic in the country. As of the year 2000 in ten reporting provinces, 717 people have tested HIV positive out of 61,130 blood samples tested, from both voluntary testing and blood donor screening. There have been 190 reported AIDS cases and 72 people have died of AIDS. The provinces reporting the highest number of people testing positive for HIV are Savannakhet, Vientiane Municipality and Champasak. The number of HIV cases in these provinces in 1999 and 2000 was 125, 78 and 34, respectively. A majority of the people with HIV are males aged 20-29, and the primary mode of transmission is through heterosexual intercourse 1. Case reports from Savannakhet indicate that most HIV diagnoses are in male seasonal migrant workers to Thailand who are already displaying opportunistic infections associated with AIDS. The second most populous group testing positive in Savannakhet have been service women who exchange sex for money. A small number of ad hoc surveys have been done of HIV and STI prevalence in the past. However, there was no coordinated strategy for monitoring trends over time, identifying high risk groups or monitoring risk behaviors. At the recommendation of the NCCA, non-governmental organizations working in HIV/AIDS and partner organizations, it was decided that the rapid implementation of a second generation HIV surveillance system 2, studying HIV-related risk behavior and the prevalence of HIV and other sexually transmitted infections, was critical to provide understanding of the situation and inform prevention and control programs in Lao PDR. This report deals with the HIV Sentinel Surveillance (HSS) and Sexually Transmitted Infection Periodic Prevalence Survey (SPPS), which was conducted in Lao PDR during 2001 and coordinated by the NCCA with Family Health International, the Lao PDR HIV/AIDS Trust, World Health Organization, Control of HIV/AIDS/STD Partnership Project in the Asia region (CHASSPAR), and the European Union/STD Project. The Behavioral Surveillance Survey (BSS) component of the surveillance was conducted earlier ( ) and is reported elsewhere 3. Introduction 5

11 6 HSS and SPPS : Lao People s Democratic Republic, 2001

12 BACKGROUND The World Health Organization (WHO) and Joint United Nations Program on HIV/AIDS (UNAIDS) recommend conducting HIV surveillance that is flexible to adjust to changing stages of an epidemic, provides an understanding of trends over time including the behaviors that drive the epidemic, and is focused on sub-populations at highest risk - so called Second generation HIV surveillance 2. Following that model, and after consultation between the NCCA, various Government Departments and national and international non-government organizations, a strategy was developed for combined Behavioral Surveillance Survey (BSS) - HIV Surveillance Survey (HSS) - Sexually Transmitted Infection Periodic Prevalence Survey (SPPS). Target populations were selected for the first stage (BSS) based on the suspected level of HIV risk activity, and accessibility. The provinces were chosen on the basis of population density, HIV case reporting, the existence of significant numbers of the target populations, and including different demographic regions of the country. Table 1 shows the target populations and Provinces included in the two stages of the survey. The BSS was carried out approximately 6 months before the HSS-SPPS. Based on the experience of the BSS, target populations were reviewed for the HSS-SPPS. The HSS-SPPS was logistically more difficult, requiring appropriate handling, processing, storage and analysis of biological specimens. Also taken into consideration were difficulties encountered during the BSS in identifying representative samples of some populations. The target populations for the HSS-SPPS were therefore limited to service women, female factory workers and long distance truck drivers (Table 1). They were selected as sentinel high-risk populations that were accessible to the survey and not necessarily the only high-risk populations in Laos. Table 1: Target populations included in BSS-HSS-SPPS Population BSS HSS-SPPS Service Women Vientiane Municipality Luang Prabang Khammuane _ Savannakhet Champasak _ Female Factory Workers (Vientiane Municipality) Seasonal Migrant Workers _ (male and female) Khammuane, Savannakhet, Champasak Long Distance Truck Drivers Vientiane Municipality, Champasak Military _ Vientiane Municipality, Luang Prabang, Khammuane, Savannakhet, Champasak Police _ Vientiane Municipality, Luang Prabang, Khammuane, Savannakhet, Champasak Background 7

13 The participating Provinces were also limited to Luang Prabang from Northern Laos, two major metropolitan areas from the Central region (Vientiane Municipality, Savannakhet), and one from the South (Champasak). Service Women (Vientiane Municipality, and Luang Prabang and Savannakhet Provinces) Formal, brothel-based sex work is rare in Laos, and prostitution is illegal. Defining and identifying women who sell sex for money in Laos can be particularly difficult. However, commercial sex can be obtained from women who work in small drink shops and nightclubs. For women working in these establishments, service may include serving food or beer, having conversation with their customers, and/or negotiation of commercial sex transactions. Therefore the term commercial sex worker does not apply to all of these women. To develop a better understanding of the behavioral risks of service women, the study did not screen participants to find out whether they were commercial sex workers. Instead, all women who worked in these establishments and had direct contact with the patrons were included. usually 10:00 pm. If women were not back in the dormitories by the time of curfew, they were not allowed to enter and had to spend the night off grounds. Male Long Distance Truck Drivers (Vientiane Municipality and Champasak Province) Truck drivers are considered to be a mobile population because they often spend long periods of time away from their family and have the opportunity to stay out overnight either in Laos or another country. This time away from their communities offers greater opportunities with fewer social constrictions to have multiple sexual partners - including commercial sex partners. For this reason, truck drivers are a population with potentially high risk for acquiring HIV. This population includes both the drivers and drivers assistants. All truck drivers included in the survey were males who drove long distance routes either within Lao PDR or across international borders. Female Factory Workers (Vientiane Municipality) Factory workers were included as a potentially high risk population because they were living away from their home communities, and therefore had less social constrictions on sexual contact. These women were considered internal (domestic) migrants because a majority had left their homes and families to seek work in the city. There are anecdotal reports of casual and commercial sex amongst this group, both in Laos and other South East Asian countries. It was thought important to quantify the level of risk activity by including them in the survey. The factory workers selected for this study were all women working in small to large garment factories in Vientiane Municipality and living in dormitories either on the factory grounds or nearby. The factory-owned dormitories had strict regulations and curfews, 8 HSS and SPPS : Lao People s Democratic Republic, 2001

14 M METHODOLOGY Sampling Sampling frames were developed by mapping target populations. Mapping of each target population in each Province was carried out by staff of the Provincial Committee for the Control of AIDS (PCCA). As these staff had previously carried out mapping for these populations for the BSS, they received a oneday refresher mapping training course. Mapping was done approximately one month before the commencement of field work. For female factory workers, the number of workers were recorded in every garment factory in the Vientiane Municipality, by viewing staff lists provided by the management. For service women, mapping included recording the number of service women working in every small drink shop and nightclub. The geographic areas included were the metropolitan areas of Vientiane Municipality, Savannakhet city and Luang Prabang Township, and Nam Bak District in Northern Luang Prabang Province. For truck drivers, all major truck stops in Vientiane Municipality Municpality and Champasak Provinces were monitored to record the number of different trucks encountered over a 6-week period. In Vientiane Municipality there were 6 truck stops included - 4 within the metropolitan area, plus the Friendship Bridge border crossing, and Tanelang Warehouse, servicing cross-border trade. In Champasak 5 truck stops were included - 3 within Pakse metropolitan area and 2 at the border crossing, Punthong District. Sample sizes were calculated based on the number required to detect a 10% change in behavior or prevalence over time. Where the total population was found to be close to, or below this number, the entire population was included ( take all ). Where the population exceeded the sample size required, two-stage cluster sampling was used. Selection of clusters was based on probability proportionate to size. In Vientiane Municipality four small drink shops were found to have closed before the commencement of field work. A second round of cluster selection was done to provide four replacement establishments. The selection of participants within each cluster was by simple random sampling - 5 per cluster for service women, and 10 for female factory workers. Teams visited factories, small drink shops and nightclubs at a time negotiated with the owner/manager, and the participants were selected randomly from a list of staff. Truck stops were visited on a rotating basis, usually one site per day. All drivers at the truck stop were asked to participate. Sample sizes and method of sampling for each target population in each Province are listed in Table 2. Methodology 9

15 Table 2: Total Sample Size by Target Groups and Sites, and Sampling Methodology Population Total size of Sampling Sampling Participants Number of sampling universe size method selected per cluster clusters selected Female Factory Workers Vientiane Municipality Cluster: st stage PPS* 2 nd stage random Service Women Vientiane Municipality Cluster: st stage PPS 2 nd stage random Luang Prabang Take all Savannakhet Take all Truck Drivers Vientiane Municipality Take all Champasak Take all * PPS : Probability proportionate to size Field work and data collection Data collection took place over 6 weeks from February to April There were 9 field teams, each team working with only 1 target group (table 1). Each team consisted of 4-5 members; team leader, interviewer(s) (2 for factory workers, 1 for service women and truck drivers), laboratory technician and driver. Survey teams were recruited by the relevant Provincial Committee for the Control of AIDS (PCCA) and team members were residents of the Province in which the field work was to be conducted. Numbers of survey teams for each target group are shown in table 3. All STI testing was anonymous and Table 3: Survey teams Population Number of survey teams Female Factory Workers Vientiane Municipality 2 Service Women Vientiane Municipality 2 Luang Prabang 1 Savannakhet 1 Truck Drivers Vientiane Municipality 1 Champasak 1 verbal informed consent was given prior to the start of the interview. Team leaders were medical practitioners. Their role included; logistical arrangements for their team negotiation with owners and managers of survey sites selection of participants at each site answering participants questions after their interview provision of drugs for treatment of STI symptoms, according to national STD case syndrome management guidelines provision of condoms, IEC materials and a small gift (first aid kit) to participants referrals for STI testing and treatment checking all documentation and completed questionnaires 10 HSS and SPPS : Lao People s Democratic Republic, 2001

16 Interviewers came fr om a range of backgrounds as selected by the PCCA, but were mostly health care workers. They were the same gender as the participants and their role included; obtaining verbal informed consent from participants administering the questionnaire The questionnaire was a condensed version of that used in the BSS. It included approximately 30 questions on demographics, sexual behavior, genito-urinary symptoms and treatment. All completed questionnaires were checked by a NCCA staff member. Feedback on the results of these reviews was provided to team leaders and interviewers as required. Laboratory technicians were all qualified and currently working as medical laboratory technicians. Their role included; taking blood samples from participants giving instructions to the participant on providing first void urine sample labeling, storage and transport of specimens processing of samples (eg. Centrifuging and decanting) performance of tests for syphilis and HIV serology Blood and urine samples were taken immediately after the administration of the questionnaire. Blood was allowed to clot at room temperature for up to 2 hours. Urine was stored in a cold box at 4-8 C. After completion of field work for the day samples were transported to the Provincial laboratory for processing. Blood samples were centrifuged, and serum decanted. The syphilis and HIV tests were usually conducted on the same day. Urine samples were shaken and decanted into cryotubes. Samples were stored at 4 C and within one week transported by air, accompanied, to the Center for Laboratory and Epidemiology (CLE), Vientiane Municipality. Handling and storage conditions were recorded on laboratory data forms. Samples were inspected on receipt at CLE each week and problems documented. At the CLE urine samples were frozen at -70 C. They were transported by air on dry ice to Bangkok for analysis for chlamydial and gonococcal infection. A position of Central Supervisor was created to provide supervision of field work in each Province. These supervisors were senior NCCA and CLE staff, using standard supervision checklists. A 10-day training course was provided for all team members. Training included team building, concurrent skills development sessions for team leaders, interviewers and lab technicians, and trial field work. A separate 3- day training course was conducted for Central Supervisors. Laboratory testing Serum samples were analyzed for HIV antibody (Particle Agglutination - Serodia) and syphilis serology (RPR - Biotec) at the nearest Provincial laboratory. RPR was carried out on undiluted serum. Confirmatory testing was performed at the Center for Laboratory and Epidemiology, Vientiane Municipality. Samples positive for HIV by PA were confirmed by ELISA (Genscreen), and RPR positives by TPHA (Biotec). Thirty percent of HIV-negative samples were randomly selected for screening by ELISA for false negatives. Thirty percent of RPR-negative samples were randomly selected for screening by TPHA as a marker of previous or current syphilis. Urine was analyzed for Chlamydia trachomatis and Neisseria gonorrheae using Roche manual microplate Amplicor CT/NG PCR, at the Bangrak Hospital Laboratory of the Division of Venereal Diseases, Ministry of Public Health, Thailand. Quality control of the PCR testing was carried out at the CDC/ HIV/AIDS Collaboration Laboratory, Bangkok, using the Roche automated COBAS Methodology 11

17 Amplicor CT/NG PCR test. The quality control testing was done on 100 previously unopened aliquots, including 50 positive and 50 negative samples and samples from all four Provinces. Data analysis Data were entered using Epi Info. Behavioral data were double entered and checked for discrepancies. Data entry of each laboratory result was double-checked. Data analysis was carried out using STATA version 7, using survey commands for the analysis of data collected by cluster sampling. The results presented include 95% confidence intervals for some populations but not others. This is because different sampling methods were used for different populations. Where cluster sampling was used (female factory workers, service women in Vientiane Municipality) the results are estimates, and therefore a confidence interval is necessary to show the precision of our estimate. However, where the whole population was sampled, ( take all sampling for service women in Savannakhet and Luang Prabang, and all long distance truck drivers), there is no need for a confidence interval because the results are final and complete for the whole population. Where populations using two different methods of sampling are combined (total service women), confidence intervals are needed because the whole population was not included in the sample. Ethical approval This study was approved by the Ministry of Health Lao PDR and the Protection of Human Subjects Committee of Family Health International. 12 HSS and SPPS : Lao People s Democratic Republic, 2001

18 R RESULTS Final participant numbers and response rates The number of participants required in the study design and the actual number surveyed are presented in Table 4. For female factory workers, the number of participants was the same as the designed sample size (300) and there were no refusals. For service women in Vientiane Municipality, two refusals to participate were recorded, and they were replaced by other participants randomly selected from the same cluster. Two participants could not provide satisfactory blood and urine samples, and were therefore excluded from the analysis. In Savannakhet the total number of service women encountered during the field work was 300, slightly less than the total encountered during mapping, due to the closure of two establishments before the commencement of field work. During field work in Luang Prabang, the combined total number of service women working in the township of Luang Prabang and District of Nam Bak was found to be 210, slightly more than the total found during mapping (200). For long distance truck drivers in Vientiane Municipality, the total number of drivers encountered during field work was 152, two more than the number found during mapping (150). However, two participants could not provide satisfactory urine and blood samples, and were therefore excluded from the analysis. In Champasak, the total number of drivers was exactly the same as that estimated during mapping (150). Table 4: Desired and actual sample sizes. Population Desired* Actual** sample size sample size Female Factory Workers Vientiane Municipality Service Women Vientiane Municipality Luang Prabang Savannakhet Total service women Truck Drivers Vientiane Municipality Champasak Total truck drivers Total 1,430 1,411 * The number ofparticipants required or estimated, according to study design ** The number of participants who successfully completed a questionnaire and provided satisfactory blood and urine samples Results 13

19 Demographic Characteristics Age Female factory workers were the youngest population, with an average age of 20.3 years. More than half (50.6%) were between 15 and 19 years. Service women had an average age of 21.7 years, 39.8% were between 15 and 19 years. The mean ages for the Provinces were significantly different from each other, service women were youngest in Luang Prabang (average 20.1 years), followed by Vientiane Municipality (average 21.5 years) and oldest in Savannakhet (average 23.2 years) (P<0.05, Table 5). Truck drivers had an average age of 34.8 years, the majority (69.0%) being 30 years or older. There was little difference in age between those in Champasak (average 35.1 years) and Vientiane Municipality (average 34.5 years) (Table 5). Marital status, mobility, education Female populations Female factory workers were nearly all unmarried and not living with a partner (98.7%), as is to be expected from a young population that is living in dormitories. They had an average of 7.1 years education (Table 6). All those in the survey were currently living in dormitories in Vientiane Municipality. Their home Province was most commonly Vientiane Municipality Province (22.7%), followed by Huaphanh (17.9%), Vientiane Municipality (10.7%), Luang Prabang (10.1%) and Savannakhet (9.3%). A majority of service women were unmarried and not living with a partner (83.0%), but those in Vientiane Municipality were significantly more likely to be married and living with their husband (10.5%) compared to Luang Prabang (0%) and Savannakhet (1.7%) (p<0.05). Service women in Luang Prabang were nearly all unmarried and not living with a partner (98.1%), while for those in Table 5: Age groups and mean age Population >30 Mean age n(%): (95% CI) n(%) : (95% CI) n(%) : (95% CI) n(%) : (95% CI) n(%) : (95% CI) (95% CI) Female Factory Workers 0(0) 151(50.6) 111(35.8) 33(11.8) 5(1.7) 20.3 N=300 (44.0, 57.3) (30.4, 41.7) (8.9, 15.6) (0.7, 4.3) (19.8, 20.8) Service Women Vientiane Municipality 0(0) 120(39.8) 122(39.7) 42(14.2) 17(6.3) 21.5 N=301 (32.5, 47.6) (32.9, 46.9) (9.7, 20.2) (3.3, 11.7) (20.7, 22.3) Luang Prabang 5(2.4) 116(55.2) 54(25.7) 27(12.9) 8(3.8) 20.1 N=210 Savannakhet 0(0) 77(25.7) 127(42.3) 65(21.7) 31(10.3) 23.2 N=300 Total 5(0.4) 313(39.1) 303(38.2) 134(15.6) 56(6.8) 21.7 N=811 (0.1, 1.0) (33.5, 45.0) (33.5, 43.1) (12.2, 19.6) (4.4, 10.1) (21.0, 22.3) Truck Drivers Vientiane Municipality 0(0) 4(2.7) 21(14.0) 26(17.3) 99(66.0) 34.5 N=150 Champasak 0(0) 3(2.0) 17(11.3) 19(12.7) 108(72.0) 35.1 N=150 Total 0(0) 7(2.3) 38(12.7) 45(15.0) 207(69.0) 34.8 N= HSS and SPPS : Lao People s Democratic Republic, 2001

20 Savannakhet, 5.0% were married but not living with their husband, and 4.3% were unmarried and living with a partner. They had an average of 6.7 years of education. Service women in Vientiane Municipality had the most education (7.1 years) followed by Luang Prabang (6.1 years) and Savannakhet (5.7 years)(p<0.05). About half were currently living in their home Province (56.5%). Of those interviewed in Luang Prabang Province, 18.6% were interviewed in Nam Bak District and the remainder around Luang Prabang Township. They were most likely to be living in their home Province (95.2%). For those interviewed in Savannakhet 62.3% were living in their home Province, the remainder were most likely to be from Vientiane Municipality (15.0%), Vientiane Municipality Province (5.7%) and Khammuane (5.7%). Those interviewed in Vientiane Municipality were least likely to be living in their home Province (45.6%, P<0.05), 18% were from Vientiane Municipality Province, 8.9% from Xiengkwang, 5.8% from Luang Prabang and 5.7% from Huaphanh (Table 6). Long Distance Truck Drivers Eighty percent of truck drivers were married and living with their wives, higher in Champasak (83.3%) than Vientiane Municipality (76.7%), and almost all of the others were unmarried and not living with a partner (Table 6). They had more education than the female populations (9.1 years), and those interviewed in Vientiane Municipality (9.9 years) more than Champasak (8.3 years). They had been truck drivers for an average of 11.1 years. Seventy two percent were living in the Province where they were interviewed. Of those interviewed in Vientiane Municipality, 28% were interviewed at Tanelang Warehouse, 12% at the Friendship Bridge and 60% at truck stops within the metropolitan area. Sixty six percent were living in Vientiane Municipality, 20.0% in Xiengkwang and 8.7% in Luang Prabang. Of those interviewed in Champasak, 76.7% were interviewed at the customs checkpoint and 12.7% at the border warehouse in Punthong District, and 10.7% at truck stops within the Pakse township. Seventy eight Table 6: Marital status, percent living in their home Province, and mean years of schooling. Population Married & living Not married and Interviewed Mean years with partner not living with partner in home province of school n(%): (95% CI) n(%) : (95% CI) n(%) : (95% CI) (95% CI) Female Factory Workers 0(0) 297(98.7) 35(10.7) 7.1 N=300 (96.0, 100, 0) (6.8, 16.3) (6.8, 7.4) Service Women Vientiane Municipality 29(10.5) 254(83.0) 143(45.6) 7.1 N=301 (6.6, 16.3) (76.8, 87.8) (39.1, 52.4) (6.7, 7.5) Luang Prabang 0(0) 206(98.1) 200(95.2) 6.1 N=210 Savannakhet 5(1.7) 265(88.3) 187(62.3) 5.7 N=300 Total 34(7.0) 725(86.4) 530(56.5) 6.7 N=811 (4.5, 11.0) (82.0, 89.9) (50.8, 62.1) (6.4, 7.0) Truck Drivers Vientiane Municipality 115(76.7) 31(20.7) 99(66.0) 9.9 N=150 Champasak 125(83.3) 24(16.0) 117(78.0) 8.3 N=150 Total 240(80.0) 55(18.3) 216(72.0) 9.1 N=300 Results 15

21 percent were living in Champasak, 8.0% in Vientiane Municipality and 7.3% in Savannakhet. Seventy five percent had stayed away from home overnight in Laos in the past three months, with little difference between those interviewed in Vientiane Municipality (74.0%) and Champasak (75.3%). Drivers spent an average of 9.4 days each month away from home. Those interviewed in Vientiane Municipality tended to stay out in central and northern parts of the country - Vientiane Municipality (41.4%), Luang Prabang (32.4%), Vientiane Municipality Province (26.1%), and Oudomxay (25.2%). Those interviewed in Champasak tended to stay out overnight in southern Provinces - Champasak (77.0%), Sekong (21.2%), Attapeu (18.6%) and Saravane (13.3%). Sixty percent of drivers had ever driven into another country, 42% do so at least once per week - again with little difference between those interviewed in Vientiane Municipality (44.8%) and Champasak (40.4%). Those interviewed in Vientiane Municipality tended to stay out in areas bordering central and northern Laos - Nong Khai Province, Thailand (50.8%), Yunan Province, China, (31.3%) and Vietnam (20.9%). Those interviewed in Champasak tended to stay out in Ubon Ratchatani Province, Thailand (97.4%). Sexual Activity and Condom Use Three types of sex partners are looked at in this study. Commercial partners are those who had sex in exchange for money. For the females in the study this means they were paid for sex. For the truck drivers this means they paid money to another person to have sex with them. The exchange of non-monetary gifts is not included because it creates a gray area around the division between commercial and non-regular sex partners. Regular partners are defined as either spouses or live-in sex partners. A non-regular partner is any sex partner who is not a regular or a commercial partner. A non-regular partner may be a long term girlfriend of many years or a one time sexual encounter. Such sexual relationships are considered higher risk than sex with a regular partner. Female Populations Female factory workers reported very little sexual activity. Only 14.1% reported ever having sex. For those who had had sex their average age at the first time was 17.5 years. Only 1.4% reported having a regular partner in the past 12 months, 7.4% had a non-regular partner. Selling sex was, reportedly, almost completely absent (0.4%) (Table 7). For service women, 92.4% reported they had ever had sex, significantly higher in Savannakhet (98.0%) than in Vientiane Municipality (90.6%) and Luang Prabang (91.9%) (P<0.05, Table 7). The average ages at first sex were 17.5 years for Vientiane Municipality, 16.8 for Luang Prabang and 17.9 for Savannakhet. Nineteen percent reported having a regular partner in the past year, there were significant differences between the 3 Provinces, highest in Vientiane Municipality (22.7%), then Luang Prabang (16.2%) Savannakhet (11.0%) (P<0.05). Forty nine percent reported sex with a non-regular partner in the past year, with significant differences between the Provinces, much higher in Luang Prabang (64.3%), followed by Savannakhet (52.3%) and lowest in Vientiane Municipality (44.3%) (P<0.05). Only 65.5% reported selling sex in the past year, and again there were large differences between Provinces with 78.0% in Savannakhet, 70.5% in Luang Prabang, and only 60.2% in Vientiane Municipality (P<0.05). There were also large statistically significant differences in the reported total number of partners in the past year, from an average of 36.1 in Savannakhet, down to 8.6 in Vientiane Municipality and only 3.2 in Luang Prabang (P<0.05). 16 HSS and SPPS : Lao People s Democratic Republic, 2001

22 Table 7: Females; ever had sex, sex with regular, non-regular and commercial partners, and total number of partners. Population Sex with Sex with non- Sex with Ever had sex regular partner regular partner commercial partner n(%) : (95% CI) in last 12 months in last 12 months in last 12 months n(%) : (95% CI) n(%) : (95% CI) n(%) : (95% CI) Mean no. partners in last 12 months (95% CI) Female Factory Workers 40(14.2) 4(1.4) 20(7.4) 1(0.4) 0.1 N=300 (9.8, 20.1) (0.5, 4.1) (4.3, 12.5) (0.0, 2.7) (0.1, 0.1) Service Women Vientiane Municipality 272(90.6) 62(22.7) 134(44.3) 185(60.2) 8.6 N=301 (84.2, 94.6) (17.5, 28.9) (37.3, 51.6) (51.0, 68.8) (5.9, 11.4) Luang Prabang 193(91.9) 34(16.2) 135(64.3) 148(70.5) (3.2) N=210 Savannakhet 294(98.0) 33(11.0) 157(52.3) 234(78.0) 36.1 N=300 Total 759(92.4) 129(19.2) 426(49.0) 567(65.5) 13.7 N=811 (88.3, 95.1) (15.5, 23.6) (43.8, 54.2) (59.0, 71.5) (9.6, 17.7) Service women with a regular partner had sex with that partner an average of 3.4 times in the past month, significantly lower in Luang Prabang (1.0, P<0.05). Condom use with the regular partner was low at 18.4% for last sex and 8.9% every time in the past year (Table 8). Service women with at least 1 non-regular partner in the past year had sex with the last one an average of 2.3 times in the past month. Condom use was higher than for regular partners, with 25.4% reporting using a condom every time in the last year with a non-regular partner. There was little difference between Provinces, ranging from 24.5% in Vientiane Municipality to 28.0% in Vientiane Municipality (Table 9). Those who reported selling sex in the past year had an average of 19.5 clients in the year. There were large statistically significant differences between the three provinces, the lowest being Luang Prabang (3.1 clients per year), followed by Vientiane Municipality (12.8) and up to 45.4 in Savannakhet (P<0.05). Reported condom use was higher than for non-regular partners (90.3% at last sex, 60.1% every time in past month), Luang Prabang Table 8: Service women; sexual contact and condom use for those who report contact with a regular sex partner in the past year. Population Mean # times had Had sex with Used condom Used condom with sex with regular regular partner with regular regular partner every partner in last month in last week partner at last sex time, last 12 months (95% CI) n(%) : (95% CI) n(%) : (95% CI) n(%) : (95% CI) Service Women Vientiane Municipality (35.3) 13(21.0) 6(10.8) N=62 (2.1, 5.4) (24.0, 48.5) (12.2, 33.7) (4.6, 23.1) Luang Prabang 1.0 2(5.9) 6(17.7) 1(2.9) N=34 Savannakhet (51.5) 1(3.0) 1(3.0) N=32 Total (33.6) 20(18.4) 8(8.9) N=124 (2.2, 4.7) (24.5, 44.1) (11.5, 28.0) (4.1, 17.9) Results 17

23 Table 9: Service women; sexual contact and condom use for those who report contact with non-regular sex partners in the past year. Population Mean # times had sex Had sex with Used condom Used condom with nonwith last non-regular non-regular partner with non-regular regular partners every partner in past month in last week partner at last sex time, last 12 months (95% CI) n(%) : (95% CI) n(%) : (95% CI) n(%) : (95% CI) Service Women Vientiane Municipality (23.4) 56(42.4) 33(24.5) N=134 (1.5, 2.3) (15.9, 33.1) (33.8, 51.5) (17.3, 34.0) Luang Prabang (38.5) 49(36.3) 34(25.2) N=135 Savannakhet (49.0) 61(38.9) 44(28.0) N=157 Total (32.2) 166(40.4) 111(25.4) N=426 (2.0, 2.6) (25.7, 39.5) (34.8, 46.3) (20.5, 31.1) service women reporting significantly lower rates (49.3% every time in last month) than Vientiane Municipality (60.0%) and Savannakhet (71.4%) (P<0.05). The median price for sex was 200,000 Kip (equivalent to 1,000 Baht) (Table 10). Government workers and businessmen were the most commonly reported commercial sex clients, with 43.1% and 34.5% of the reported last 3 clients, respectively. Other occupations were much less commonly reported, such as soldiers or policemen (5.9%) and truck or taxi drivers (1.4%). Service women in Luang Prabang reported more government workers (51.8%), soldiers and police (9.8%), and fewer businessmen (19.3%) compared to other Provinces (P<0.05). Those in Vientiane Municipality reported fewer government workers (34.7%) and more businessmen (34.7%) and tourists (8.3%) compared to the other Provinces (P<0.05). Those in Savannakhet reported mostly government workers (52.3%) and businessmen (36.1%) (Figure 1). Long Distance Truck Drivers Almost all long distance truck drivers reported that they had had sex (96.7%), the average age at first sex was 19.9 years. There was little difference between those interviewed in Vientiane Municipality (96.0%, average age 19.7) and Champasak (97.3%, average age 20). The majority of truck drivers reported having a regular partner (81.7%), Vientiane Municipality (79.3%) and Champasak (84.0%). Vientiane Municipality drivers were more Table 10: Service women; sexual contact and condom use for those who report commercial sex in the past year. Population Mean no. clients Used condom with Used condom with client Median price in past 12 months client, last sex every time in last month for sex, last client (95% CI) n(%) : (95% CI) n(%) : (95% CI) Kip Service Women Vientiane Municipality (90.3) 110(60.0) 300,000 N=185 (8.8, 16.8) (84.0, 94.3) (50.3, 69.1) Luang Prabang (58.8) 73(49.3) 200,000 N=148 Savannakhet (94.4) 167(71.4) 200,000 N=234 Total (86.3) 350(60.1) 200,000 N=567 (13.8, 25.2) (81.5, 90.0) (54.6, 67.4) 18 HSS and SPPS : Lao People s Democratic Republic, 2001

24 Figure 1: Occupation of clients of service women Percent 60 Vientiane Luang Prabang Savannakhet Total Govt. Business Company Army/police Tourist truck/taxi Other likely to report having a commercial partner (50.0%) than a non-regular partner (16.7%). For Champasak drivers, however, non-regular partners (29.3%) were about as common as commercial partners (31.3%). The mean number of partners in the past year was 3.0, higher in Vientiane Municipality (3.6) than Champasak (2.4) (Table 11). Those who had a regular partner reported having sex with them an average of 6.8 times in the past month. Reported condom use was quite low, only 5.3% at last sex, and 1.2% every time in the past year (Table 12). For those who reported having a nonregular partner, they had sex an average of only 0.7 times in the past month with their last non-regular partner. Reported condom use was higher than for regular partners, with 40.6% claiming to have used a condom last time, and 26.1% using a condom every time with a non-regular partner in the past year. Condom use was lower in drivers in Vientiane Municipality (16.0% every time in last year) than Champasak (31.8%) (Table 13). A large percentage of drivers reported having paid for sex in the past year (40.7%) and of those, 54.9% reported having done it 3 or more times in the year (22.3% of all drivers). Paying for sex was reported more commonly by drivers in Vientiane Municipality (50.0%) than Champasak (31.3%). In Vientiane Municipality, of those who reported having paid for sex in the past year, 66.7% had done so 3 times or more in the past year. Reported condom use every time in the past year was 44.3%, higher in Champasak (61.7%) than Vientiane Municipality (33.3%) (Table 14). The most common place that the last commercial partner was found was a small drink shop (59.0%), followed by a nightclub (13.1%), on the street (9.8%) and a guesthouse (8.2%). The street was more commonly reported by Vientiane Municipality drivers (14.7%) than Champasak drivers (2.1%), while Results 19

25 Table 11: Long distance truck drivers; ever had sex, sex with regular, non-regular and commercial partners, and total number of partners. Population Sex with Sex with non- Sex with Ever had sex regular partner regular partner commercial partner Mean no. partners n(%) in last 12 months in last 12 months in last 12 months in last 12 months n(%) n(%) n(%) Truck Drivers Vientiane Municipality 144(96.0) 119(79.3) 25(16.7) 75(50.0) 3.6 N=150 Champasak 146(97.3) 126(84.0) 44(29.3) 47(31.3) 2.4 N=150 Total 290(96.7) 245(81.7) 69(23.0) 122(40.7) 3.0 N=300 Table 12: Long distance truck drivers; sexual contact and condom use for those who report contact with a regular sex partner. Population Mean # times had sex with regular partner in last month Had sex with regular partner in last week n(%) Used condom with regular partner at last sex n(%) Used condom with regular partners every time, last 12 months n(%) Truck Drivers Vientiane Municipality (73.1) 6(5.0) 0(0) N=121 Champasak (56.4) 7(5.6) 3(2.4) N=126 Total (64.5) 13(5.3) 3(1.2) N=247 Table 13: Long distance truck drivers; sexual contact and condom use for those who report contact with non-regular sex partners Population Had sex with Used condom Used condom with non- non-regular partner with non-regular regular partners every in last week partner at last sex time, last 12 months n(%) n(%) n(%) Mean # times had sex with last non-regular partner in past month Truck Drivers Vientiane Municipality 1.6 3(12.0) 8(32.0) 4(16.0) N=25 Champasak 0.2 2(4.6) 20(45.5) 14(31.8) N=44 Total 0.7 5(7.3) 28(40.6) 18(26.1) N=69 Table 14: Long distance truck drivers; sexual contact and condom use for those who report commercial sex in the past year. Population Had 3 or more commercial Used condom with commercial Used condom with commercial partners in last 12 months partner at last sex partners every time, last 12 months n(%) n(%) n(%) Truck Drivers Vientiane Municipality 50(66.7) 38(50.7) 25(33.3) N=75 Champasak 17(36.2) 34(72.3) 29(61.7) N=47 Total 67(54.9) 72(59.0) 54(44.3) N= HSS and SPPS : Lao People s Democratic Republic, 2001

26 Figure 2: Where last commercial partner was found Other : 10% Street : 10% Guesthouse : 8% Small drink shop : 59% Nightclub : 13% a nightclub was more common for Champasak drivers (25.5%) than Vientiane Municipality drivers (5.3%) (Figure 2). The median price of the last occasion of commercial sex was 50,000 Kip. No truck drivers reported having sex with a man in the past year. Genito-urinary symptoms Female factory workers reported the lowest prevalence of symptoms, both currently (3.5%) and in the past year (5.7%) (Table 15). Service women reported a much higher prevalence of symptoms; 20.8% currently, and 38.9% in the past year. A much lower prevalence of symptoms in the past year was reported from Luang Prabang (20.0%) compared to Vientiane Municipality (42.8%) and Savannakhet (40.3%) (P<0.05). Current symptoms were more prevalent in Vientiane Municipality (24.5%) than Luang Prabang (15.7%) or Savannakhet (13.3%) (P<0.05). Of service women who had symptoms in the past year 78.9% received treatment, higher in Savannakhet (91.1%) than Vientiane Municipality (75.7%) and Luang Prabang (74.0%) (P<0.05) (Table 15). Amongst service women, those reporting genito-urinary symptoms in the past year were more likely to report having 10 or more partners in the past year (odds ratio 1.95, p=0.002). An association between reporting symptoms and ever having sex was not statistically significant (odds ratio 3.5, p=0.054). There was no association between reporting symptoms and reporting selling sex in the past year. For truck drivers, the reported prevalence of current symptoms was 4.7% and symptoms in the past year 11.0%. There was a marked difference between the Provinces, with higher rates reported from Vientiane Municipality (8.7% current and 18.0% in past year) than Champasak (0.7% and 4.0%) (Table 15). Of those who reported symptoms in the past year 97.3% reported receiving treatment. In female factory workers the most commonly reported symptoms were unusual vaginal discharge (28.0% of reported symptoms), vaginal smell (25.6%) and itching (25%). For service women, the symptoms were predominantly vaginal discharge (45% of reports), itching (21%) and unusual vaginal smell (18%) (Figure 3). Blisters were uncommon (3% of reports), as were ulcers or sores (2%). Of those who did report a symptom, 70.2% reported more than one; 100% in Luang Prabang, 79.2% in Vientiane Municipality and only 28.0% in Savannakhet. The most commonly reported combination of symptoms was vaginal discharge and itching (18.4% of service women) followed by vaginal discharge and vaginal smell (14.4% of service women). Results 21

27 Table 15: Prevalence of genito-urinary symptoms, and treatment for those symptoms, in the past year. Population Symptom(s)-current Symptom (s)-last 12 months Treated in last 12 months n(%) : (95% CI) n(%) : (95% CI) n(%) : (95% CI) Female Factory Workers 11(3.5) 18(5.7) 14(4.6) N=300 (2.0, 6.0) (3.3, 9.7) (2.4, 8.9) Service Women Vientiane Municipality 76(24.5) 130(42.8) 98(32.4) N=301 (18.7, 31.4) (36.3, 49.5) (26.2, 39.3) Luang Prabang 33(15.7) 42(20.0) 31(14.8) N=210 Savannakhet 40(13.3) 121(40.3) 110(36.7) N=300 Total 149(20.8) 293(38.9) 239(30.7) N=811 (16.8, 25.5) (34.5, 43.5) (26.5, 35.2) Truck Drivers Vientiane Municipality 13(8.7) 27(18.0) 25(16.7) N=150 Champasak 1(0.7) 6(4.0) 7(4.7) N=150 Total 14(4.7) 33(11.0) 32(10.7) N=300 For truck drivers the most commonly reported symptoms were pain during urination (39% of reports) and urethral discharge (34%) (Figure 4). Fifteen percent of reports were blisters, and only 2% ulcers or sores. Of those who did report a symptom, 66.7% reported more than one, the same percentage in both Vientiane Municipality and Champasak. The most commonly reported combination of symptoms was pain during urination and urethral discharge (6% of drivers). Service women who were treated for symptoms in the past year most often obtained their treatment from a pharmacy (48% of reported treatments), followed by a Provincial gynecology unit (20%), and private clinic (18%) (Figure 5). There were marked differences between the Provinces. The three most common sources of treatment in Vientiane Municipality were private pharmacy (53.7%), Provincial gynecology unit (26.3%) and private clinic (19.6%). In Luang Prabang they were private pharmacy (83.9%), traditional healer (35.5%) and Provincial gynecology unit (16.1%). In Savannakhet they were private pharmacy (45.5%), private clinic (26.4%) and Provincial gynecology unit (14.6%). Compared to other Provinces, those in Luang Prabang were more likely to obtain treatment from a private Figure 3: Type of genito-urinary symptoms in last 12 months - Service Women (580 symptoms reported by 293 women) Itching : 21% Other : 11% Discharge : 45% Ulcer/sore : 2% Blister : 3% smell : 18% 22 HSS and SPPS : Lao People s Democratic Republic, 2001

28 Figure 4: Type of genito-urinary symptoms in the past year - Truck Drivers (60 symptoms reported by 33 men) Other : 10% Ulcer/sore : 2% Blisters : 15% Pain during urination : 39% Discharge : 34% Figure 5: Where treated for genito-urinary symptoms in past year - Service Women (268 treatments for 239 women) Trad. Healer : 8% Other : 6% Priv. Clinic : 18% Pharmacy : 48% Prov. Gyn : 20% Figure 6: Where treated for genito-urinary symptoms in past year - Truck Drivers (41 treatments by 32 drivers) Other : 10% Trad. Healer : 15% Priv. Clinic : 17% Pharmacy : 41% Self : 17% pharmacy and traditional healer (P<0.05), while those in Vientiane Municipality and Savannakhet were more likely to obtain treatment at a private clinic (P<0.05), and those in Vientiane Municipality were more likely to obtain treatment at a Provincial gynecology unit (P<0.05). For truck drivers the most common place for treatment was also a pharmacy (41%), followed by a Private clinic (17%) and self treatment (17%) (Figure 6). Almost all those with symptoms in the past year reported having treatment (97.3%). Results 23

29 Laboratory Results HIV infection No HIV was found in female factory workers. The prevalence of HIV in service women was 0.9%. HIV was present in service women in Vientiane Municipality (1.1%) and Savannakhet (1%), but not in Luang Prabang (0%) (Table 16). No HIV was found in long distance truck drivers (Table 16). Reactive syphilis serology No syphilis was found in female factory workers (FFW). Thirty percent of samples from female factory workers that were negative on RPR were randomly selected for TPHA testing (93 samples). None tested positive to TPHA. Therefore the estimated proportion of FFW that had ever contracted syphilis was zero. The prevalence of syphilis in service women (SW) was 0.2%. Syphilis was found in service women in Vientiane Municipality (0.4%), but not in Savannakhet or Luang Prabang (0%) (Table 16). Thirty percent of samples from service women that were negative on RPR were randomly selected for TPHA testing (248 samples). None tested positive to TPHA. Therefore the estimated proportion of SW that had ever contracted syphilis was 0.2%. The prevalence of syphilis in long distance truck drivers (LDTD) was 1.3%, in Champasak 2.0% and Vientiane Municipality 0.7% (Table 16). Thirty percent of samples from truck drivers that were negative on RPR were randomly selected for TPHA testing (89 samples). Four (4.5%) tested positive to TPHA. Therefore the estimated proportion of LDTD that had ever contracted syphilis was 5.8%. Chlamydial infection The prevalence of chlamydial infection in female factory workers was 6.6% (Table 17). No statistically significant correlations with chlamydial infection were detected. For service women the prevalence was 32.0%, significantly lower in Savannakhet (23.3%, P<0.05), while there was no significant difference between Luang Prabang (31.9%) and Vientiane Municipality (34.8%) (Table 17). For those who reported selling sex in the past year the prevalence in was 33.4% (Table 18). Either chlamydial or gonococcal infection was detected in 39.6% (Table 18). Table 16: Laboratory results for HIV and syphilis serology Population HIV infection Syphillis n(%) : (95% CI) n(%) : (95% CI) Female Factory Workers 0(0) 0(0) N=300 Service women Vientiane Municipality 3(1.1) 1(0.4) N=301 (0.3, 3.6) (0.1, 2.7) Luang Prabang 0(0) 0(0) N=210 Savannakhet 3(1) 0(0) N=300 Total 6(0.9) 1(0.2) N=811 (0.4, 2.3) (0.0, 1.7) Truck Drivers Vientiane Municipality 0(0) 1(0.7) N=150 Champasak 0(0) 3(2.0) N=150 Total 0(0) 4(1.3) N= HSS and SPPS : Lao People s Democratic Republic, 2001

30 Table 17: Laboratory results for C. trachomatis and N. gonorrheae urine PCR testing. Population Chlamydial infection Gonococcal infection CT or GC CT and GC n(%): (95% CI) n(%) : (95% CI) n(%) : (95% CI) n(%) : (95% CI) Female Factory Workers 18(6.6) 1(0.4) 19(6.9) 0(0) N=300 (3.8, 11.1) (0.0, 2.7) (4.2, 11.3) Service women Vientiane Municipality 110(34.8) 42(13.6) 124(39.7) 28(8.8) N=301 (29.2, 40.9) (9.6, 19.0) (34.0, 45.7) (5.7, 13.2) Luang Prabang 67(31.9) 34(16.2) 80(38.1) 21(10.0) N=210 Savannakhet 70(23.3) 39(13.0) 93(31.0) 16(5.3) N=300 Total 247(32.0) 115(13.9) 297(37.6) 65(8.2) N=811 (28.0, 36.2) (11.0, 17.4) (33.6, 41.8) (6.0, 11.2) Truck Drivers Vientiane Municipality 18(12.0) 2(1.3) 18(12.0) 2(1.3) N=150 Champasak 10(6.7) 2(1.3) 11(7.3) 1(0.7) N=150 Total 28(9.3) 4(1.3) 29(9.7) 3(1.0) N=300 In service women, chlamydial infection was associated with reporting ever having had sex (odds ratio 2.5, p=0.04), and being less than 20 years of age (odds ratio 1.7, p=0.02). Chlamydial infection was not significantly associated with reporting genito-urinary symptoms, selling sex in the past year, having a non-regular partner in the past year or having 10 or more partners in the past year. In service women that reported selling sex, chlamydial infection was not significantly associated with reported condom use with clients. In service women who reported having non-regular partner(s) in the past year, chlamydial infection was associated with having less than 10 partners (odds ratio 1.7, P=0.03), and using a condom. That is, those who reported using condoms at last sex were more likely to have chlamydial infection (odds ratio 2.4, P<0.01). In long distance truck drivers the prevalence was 9.3%, higher in Vientiane Municipality (12.0%) than Champasak (6.7%) (Table 17). Chlamydial infection was associated with reporting a genito-urinary symptom in the past year (odds ratio 2.0), and commercial sex (odds ratio 1.5), but not sex with a nonregular partner. Table 18: Cross-tabulation of Sold sex in the past year? by Chlamydial and Gonococcal infection Sold sex in past year? Chlamydia- Gonorrhaepositive (%) positive (%) (95% CI of %) (95% CI of %) Sold sex in past year (28.5, 38.8) (13.0, 20.9) All SW (28.0, 36.2) (11.0, 17.4) Gonococcal infection The prevalence of gonococcal infection in female factory workers was 0.4%. In service women the prevalence was 13.9%, there was no significant difference between the rates in Luang Prabang (16.2%), Vientiane Municipality (13.6%) and Savannakhet (13.0%) (Table 17). For those who reported selling sex in the past year the prevalence in was 16.6% (Table 18). Gonococcal infection was associated with reporting selling sex in the past year (odds ratio 2.1, P=0.009). It was not associated with reporting ever had sex, having a genito-urinary symptom, or age less than 20. For those who Results 25

31 reported having a non-regular partner there was no association between gonococcal infection and condom use with that partner at last sex. For those who reported selling sex, there was no association between condom use at last sex and gonococcal infection. In long distance truck drivers the prevalence was 1.3%, with no difference between Vientiane Municipality and Champasak (Table 16). Chlamydial and gonoccocal infection in those reporting never having sex Of the 260 female factory workers who reported never having sex 12(5.5%) had chlamydial infection (Table 19), and none had gonococcal infection (Table 20). Of the 52 service women that reported never having sex 9(18.4%) had chlamydial infection; 5 in Vientiane Municipality, 4 in Luang Prabang and none in Savannakhet (Table 19). Four (9.6%) had gonococcal infection (Table 20), 3 in Vientiane Municipality and 1 in Luang Prabang. Of the 10 truck drivers who reported never having sex, 1(10%) had chlamydial infection; 1 in Vientiane Municipality and none in Champasak (Table 19). None had gonococcal infection (Table 20). Quality control All positive HIV screening tests (PA) also tested positive by ELISA. Of the total 1405 samples that tested negative for HIV on PA screening, 480 (30%) were randomly selected to be tested by ELISA. All tested negative for HIV antibody. Nine samples tested positive on RPR. Five of those were confirmed by TPHA and four tested negative. Following quality control re-testing of 100 urine specimens for Chlamydia trachomatis and Neisseria gonorrheae, the original results were found to be 92% sensitive and 100% specific, which was within the precision limits of the test as defined by the manufacturer. Table 19: Cross-tabulation of ever had sex? by Chlamydial infection Ever had sex? Chlamydia-positive n(%) : (95% CI) Chlamydia-negative n(%) : (95% CI) Total Female Factory Workers Yes 6(13.2) 4(86.8) 40 (5.3, 29.2) (70.8, 94.7) No 12(5.5) 248(94.5) 260 (3.0, 9.9) (90.1, 97.0) Total 18(6.5) 282(93.4) 300 (3.8, 11.1) (88.9, 96.2) Service Women Yes 238(33.1) 521(66.9) 759 (29.0, 37.5) (62.5, 71.1) No 9(18.4) 43(81.6) 52 (8.0, 37.0) (63.0, 92.0) Total 247(32.0) 564(68.0) 811 (28.0, 36.2) (63.8, 72.0) Truck Drivers Yes 27(9.3) 263(90.7) 290 No 1(10.0) 9(90) 10 Total 28(9.3) 272(90.7) HSS and SPPS : Lao People s Democratic Republic, 2001

32 Table 20: Cross-tabulation of ever had sex? by Gonococcal infection Ever had sex? Gonorrheae-positive n(%) : (95% CI) Gonorrheae-negative n(%) : (95% CI) Total Female Factory Workers Yes 1(2.5) 39(97.5) 40 (0.3, 18.1) (81.9, 100.0) No 0(0) 260(100) 260 Total 1(0.4) 299(99.7) 300 (0.0, 2.7) (97.3, 100.0) Service women Yes 111(14.2) 648(85.8) 759 (11.2, 18.0) (82.0, 88.9) No 4(9.6) 48(90.4) 52 (3.9, 21.8) (78.2, 96.2) Total 115(13.9) 696(86.1) 811 (11.0, 17.4) (82.6, 89.1) Truck Drivers Yes 4(1.4) 263(90.7) 290 No 0(0) 10(100) 10 Total 4(1.3) 296(98.7) 300 Data variability between teams In some instances data were collected on the same target group by more than 1 team in the same Province. This occurred in Savannakhet ( 2 service women teams) and Vientiane Municipality (2 female factory worker teams, 2 service women teams). The distribution of sites or target population between teams was arbitrary, not random. For female factory workers the 2 teams sampled different establishments. Compared with team A, workers interviewed by team B were 3.2 times more likely to report ever having sex, and recorded half as many participants who reported never having sex and chlamydial infection (8 for team A, 4 for team B). There was no difference in prevalence of chlamydial or gonococcal infection. For service women in Vientiane Municipality, 2 teams surveyed different establishments. Compared with team A, those interviewed by team B were 1.8 times more likely to report current genito-urinary symptoms, reported 4.4 times fewer commercial partners and were 3 times more likely to report being married. Team B recorded all cases in Vientiane Municipality of chlamydial and gonococcal infection in those reporting never having sex (5 chlamydia, 3 gonorrheae). There was no difference between the teams in prevalence of chlamydial or gonococcal infection. In Savannakhet, 2 teams surveyed mostly the same establishments - 79% of the service woman population were interviewed in establishments where both teams were working at the same time. Service women interviewed by team A reported 3.2 times as many commercial partners and were 1.8 times as likely to report a genito-urinary symptom, compared to those interviewed by the other team. There was no difference in prevalence of chlamydial or gonococcal infection. Results 27

33 28 HSS and SPPS : Lao People s Democratic Republic, 2001

34 DISCUSSION Behavioral data Female factory workers A very high proportion of female factory workers in both the HSS-SPPS and the BSS 3 reported they had never had sex (85.8% in HSS, 90.0% in BSS). Reported selling of sex was almost absent (0.4%). Based on these levels of reported risk activity, female factory workers could not be considered a high-risk group. Service women Both the BSS and the behavioral data collected as part of this survey, show a sex industry that is largely indirect, with relatively low numbers of clients. The mean number of clients in this survey (19.5 per year) was much lower than those recorded for sex workers in Cambodia (3.5 per day), Thailand (2.5 per day), Indonesia (1.2 per day) and the Philippines (0.5 per day) 4. It is also relatively expensive, with the median price of one encounter being around one month s salary for most Government employees. It caters mainly to middle-class clients - government workers and businessmen. Tourists accounted for only 5.4% of clients. As well as low client numbers among those who do report selling sex, the surveys show a high proportion of service women who report they have never had sex (9.4% in HSS, 15.9% in BSS), or have not sold sex in the past year (39.8% in HSS, 38.9%in BSS). Levels of reported condom use with clients were relatively high in both surveys (60.1% every time in the past month in HSS-SPPS, 72.7% in BSS). The nature of sex work in Laos has been described as very different to that in other Asian countries 5. Lyttleton described the situation in the 1990s where sex work was illegal and secretive. Service women provided company to clients, but sex was not necessarily expected or guaranteed, was expensive, and several visits by the client may be required beforehand 5. This description supports the findings in this survey of relatively low numbers of clients and high cost of commercial sex. However, there have recently been anecdotal reports of the increased availability of commercial sex. The possibility exists that rapid social changes accompanying economic development will also result in changes in the nature of sex work, and this should be closely monitored as part of HIV surveillance. There were, however, considerable differences between provinces that could be important for prevention programs. Work for service women in Savannakhet tended to resemble more established sex work. They were older (23.2 years in Savannakhet, 21.7 for the 3 Provinces combined, P<0.05), had the highest proportions of women reporting Discussion 29

35 they had had sex (98.0%, 92.4% in 3 Provinces combined, P<0.05), and the highest proportion that had sold sex in the past year (78.0%, 65.5% in 3 Provinces combined, P<0.05). Most notably, for those who did report selling sex, those in Savannakhet had by far the most number of clients, (45.4 per year, 18.9 for 3 Provinces combined, P<0.05). They had the highest rate of reported condom use with clients (71.4% every time in past month, 60.1% in 3 Provinces, P<0.05) and the highest rate of treatment for genito-urinary symptoms (91.1%, 78.9% in 3 Provinces, P<0.05). In Luang Prabang the situation could be described as closer to a rural, less developed setting. The service women were younger (20.1 years, average 21.7 for 3 Provinces combined, P<0.05). They were much more likely to be living in their home Province (95.2%, 56.5% for 3 Provinces combined, P<0.05). They had by far the fewest number of clients (3.1 per year, 19.5 for 3 Provinces combined, P<0.05) and the lowest rate of reported condom use with clients (49.3% every time in past month, 60.1% for 3 Provinces, P<0.05). They also had the highest proportion reporting sex with non-regular partners (64.3% in the past year, 49.0% for 3 Provinces, P<0.05). Vientiane Municipality had the largest number of working service women (901, 330 in Savannakhet, 210 in Luang Prabang). Many came from other Provinces (55.4% of those working in Vientiane Municipality came from another Province, 4.8% of those in Luang Prabang, 37.7% in Savannakhet, P<0.05). Most notable in Vientiane Municipality was a considerable proportion who reported that their work was limited to non-sexual services. A higher proportion were married and living with their husband (10.5% in Vientiane Municipality, 0% in Luang Prabang, 1.7% in Savannakhet, P<0.05), and a higher proportion were not selling sex (did not sell sex in past year % in Vientiane Municipality, 29.5% in Luang Prabang, 22.0% in Savannakhet, P<0.05). Long distance truck drivers Both the HSS-SPPS and BSS showed that long distance truck drivers are an older, sexually experienced population (69.0% at least 30 years of age - HSS, 63.2% - BSS). They had been driving trucks for an average of 11.1 years. They were well educated (average 9.1 years of education). The majority were married (81.3% - HSS, 73.0% - BSS). Most stay out overnight away from home (74.7% in past 3 months) and most cross the border into other countries (60.3%). They spend almost one third of each month away from home (9.4 days per month). This provided opportunities for commercial sex, which was quite common (40.7% in past year - HSS, 31.2% - BSS), and a significant proportion paid for sex quite frequently (22.3 % had 3 or more partners in the past year - HSS, 21.0% - BSS). Reported condom use with commercial partners varied between surveys (44.3% every time in the past year - HSS, 74.2% - BSS, P<0.05). Again there were significant differences between provinces, particularly in mobility, showing that the road transport routes are not homogenous. Drivers interviewed in Vientiane Municipality tended to stay out overnight in Central and Northern Provinces (Vientiane Municipality 41.4%, Luang Prabang 32.4%, Vientiane Municipality Province 26.1%, Oudomxay 25.2%). When they crossed the border they drove into areas bordering the Central and Northern Provinces of Laos - Nong Khai Province Thailand (50.8%), Yunan Province China (31.3%), and Vietnam (20.9%). Those interviewed in Champasak tended to stay out overnight in southern Provinces (Champasak 77.0%, Sekong 21.2%, Attapeu 18.6% and Saravane 13.3%). When they crossed the border they drove into areas bordering Champasak - Ubon Ratchatani Province, Thailand (97.4%). Vientiane Municipality drivers were more likely to report having commercial sex (50.0% in past year, 31.3% for Champasak), while Champasak drivers were more likely to report non-regular partners (29.3% in past year, 16.7% in Vientiane Municipality). 30 HSS and SPPS : Lao People s Democratic Republic, 2001

36 Long distance truck drivers have been a significant conduit of HIV transmission in other countries and this survey has shown relatively high levels of high-risk sex amongst this group in Laos. With the predicted expansion of road transport in Laos in the future there is a clear need for prevention activities focused on them. Although they report a high frequency of commercial sex, reports from service women show that at present they make up only a small proportion of their clients. Also, the median price reportedly paid by them for sex (50,000 Kip) is considerably less than that reportedly received by service women (200,000 Kip). There are several possible explanations for this apparent discrepancy between what was reported by truck drivers and service women. Firstly, the total number of truck drivers encountered in Vientiane Municipality and Champasak during the 6 week survey was only 300. The total population of those that make up the majority of service woman clients - those defined as Government workers or Businessman - is not known but likely to be many times more than that. A high frequency of commercial sex in a small population may not feature very significantly in the activity of the whole population. Also, it is not known in what countries the truck drivers purchased their sex. It is possible that a significant proportion was purchased in another country, as the majority regularly stayed overnight in another country. It is unlikely that truck drivers obtained commercial sex inside Laos from a different type of sex worker not included in this survey, as in 80% of cases they reported finding their last commercial partner in establishments included in this survey - small drink shops, nightclubs and guesthouses. Genito-urinary symptoms Genito-urinary symptoms can be caused by a range of sexually transmitted infections, urinary tract infections, and non-infectious causes. Rates of reported genito-urinary symptoms were high in service women (38.9% with a symptom in the past year) and, as expected were lower in female factory workers (5.7%). The most commonly reported symptoms were unusual vaginal discharge (45% of reports in service women, 28% in factory workers), itching (25% for service women and factory workers) and unusual vaginal smell (18% in service women and 26% in factory workers). These symptoms are most commonly associated with bacterial vaginosis, trichomoniasis and candidiasis, which this study did not attempt to identify. Reports of ulcers and sores were uncommon (2% o f reports), which is consistent with the low rates of syphilis. Chlamydial and gonococcal infection are frequently asymptomatic in women until or unless complications develop. Rates of obtaining treatment for genitourinary symptoms were relatively high (78.9%), but that treatment was usually not sought from a qualified medical practitioner. The most common source of treatment was a private pharmacy (48% of treatments). Traditional healers were commonly consulted in Luang Prabang (35.5% of reports). In men genito-urinary symptoms are more specifically associated with particular sexually transmitted infections (STIs). The prevalence of symptoms in the past year in long distance truck drivers was 11.0%. Those symptoms were predominantly pain during urination (39% of reports) and urethral discharge (34%), which are usually associated with chlamydial and gonococcal infection. Reported prevalence of ulcers and sores was low at 2% of reports. Truck drivers were more likely than service women to have received treatment for their symptoms (97.3%). However, as for service women, that treatment was usually not from a qualified medical practitioner (41% pharmacy, 17% self treatment, 15% traditional healer). Given the relatively high levels of reported symptoms, and probably ineffective treatment, there appears to be a need for improvements in access to acceptable STD services. Discussion 31

37 Laboratory results HIV A major aim of second generation HIV surveillance in low prevalence countries is to monitor trends in high-risk groups, to guide in preventing the epidemic from becoming generalized in the wider population. HIV prevalence was found to be less than 1% in all 3 target populations included in this survey - service women (0.9%), long distance truck drivers (0%) and female factory workers (0%). While this prevalence is low compared to the prevalence in high-risk populations in bordering countries this survey indicates that HIV has entered the Lao population and the potential exists for further spread. Most case reports of HIV and AIDS have been from migrant workers returning from working in other countries. Migrant workers were not included in this survey because of the difficulties in identifying these populations and therefore getting reliable data on them. In addition to behavioral surveillance and surveillance of HIV in high risk populations, the wider availability of HIV testing and an efficient system of case reporting is likely to improve understanding of the HIV transmission and may provide information on populations not included in targeted surveys. Sexually Transmitted Infections The prevalence of reactive syphilis serology was low in all target populations. This was supported by the low reported rates of genital ulcers and sores in both men and women. The prevalence of chlamydial infection was higher than for all other sexually transmitted infections. As expected the rates were much higher for service women (32.0%) than long distance truck drivers (9.3%) and female factory workers (6.6%). The factor that was most strongly associated with chlamydial infection was age less than 20 years, as is the case internationally 6. Apart from never having sex, this was the only factor significantly associated with the prevalence of chlamydial infection. The lack of statistically significant associations between chlamydial infection and genito-urinary symptoms, commercial sex, numbers of partners and condom use are not surprising. Chlamydial infection is frequently asymptomatic in women unless complications develop. In men it is also more commonly asymptomatic than gonorrheae. These data are therefore consistent with a situation where the lack of effective treatment is the most important factor, infection may persist for a significant time, and may not be related to recently reported sexual activity. Relationship between behavioral and laboratory data Population-based surveys are designed to be used to measure characteristics at a population level and detect changes in those characteristics between surveys. It is relatively uncommon for both behavioral and laboratory data to be collected on the same individuals at the same time, as was done in this survey. This allowed direct comparison between the answers provided on the questionnaire and the laboratory results. In a small number of instances, chlamydial (9 cases) and gonococcal infection (4 cases) was detected in those reporting they had never had sex. These cases were recorded by 2 of the 5 teams surveying service women, suggesting some under-reporting of sexual activity to those teams. There were also some instances of this recorded by both teams surveying female factory workers. It is not necessarily surprising that, in any survey, a small number of people may not feel comfortable disclosing personal information. This must always be taken into consideration when interpreting behavioral data. 32 HSS and SPPS : Lao People s Democratic Republic, 2001

38 Figure 7: Prevalence of STI among female sex workers in low HIV prevalence countries 8-10 Percent Syphillis GC CT HIV Laos Phillippines Indonesia Bangladesh On a broader level, it is noted that high levels of chlamydial and gonoccocal infection were detected together with low rates of HIV and ulcerative STI, and relatively low levels of reported commercial sex. Figure 7 shows that high rates of chlamydial and gonococcal infection together with very low rates of HIV infection have been recently reported in sex workers in other Asian countries. Brunham 7 has shown that transmission of Chlamydia trachomatis can be sustained, in the absence of effective prevention and control activities, by as few as 4 partners per year, while syphilis and HIV require more - 7 and 5-13, respectively. Discussion 33

39 34 HSS and SPPS : Lao People s Democratic Republic, 2001

40 SUMMARY CONCLUSIONS HIV prevalence was low in all target groups surveyed. HIV has entered the Lao population. Case reports indicate that those who have worked outside of Laos are at greatest risk. Rates of syphilis and reported symptoms of ulcerative STD were low in all populations surveyed. Among service women there were very high rates of chlamydial infection and genito-urinary symptoms, and high rates of gonococcal infection. Government workers and businessmen were reported to be the most common commercial sex clients of service women. Compared to sex workers in many other countries, Lao service women reported a relatively low frequency of clients and relatively high rates of condom use with clients. Female factory workers living in dormitories reported low levels of sexual activity, but chlamydial infection was still present in this population. Rates of chlamydial infection were relatively high in all populations surveyed, and associated with sexual activity in general rather than commercial sex in particular. In long distance truck drivers there were significant levels of chlamydial and gonococcal infection, genito-urinary symptoms, and high levels of reported risk activity. There were significant differences between provinces in the sexual risk activity of service women and long distance truck drivers. Treatment of symptoms or STIs is predominantly not from qualified medical practitioners, which appears to be a major contributor to high rate of STIs. Summary / Conclusion 35

41 36 HSS and SPPS : Lao People s Democratic Republic, 2001

42 R RECOMMENDATIONS Prevention of HIV/STI The Lao PDR is in the fortunate position of being able to prevent a significant HIV epidemic. As contact with neighboring highprevalence countries increases this will become more challenging. HIV is present in Lao PDR, and STI transmission is a significant problem. HIV/STI prevention programs should be a high priority. Tailor prevention programs to local situation This survey has shown differences between provinces in commercial and other sexual activity, mobility and road transport. Prevention activities will benefit from flexibility to these local circumstances. Improve STI management Improvements in access to acceptable and effective treatment for STI, not just for those engaged in commercial sex but for all sexually active people, are likely to result in a significant improvement in prevalence of STI in Laos. Improve HIV case reporting Case reports indicate that in previous years the majority of cases of HIV infection and AIDS in Laos were acquired in other countries. Eventually people with HIV become sick and seek health care. At that point they can be diagnosed. Reports of these cases do not provide an early warning, but they can be an indicator of HIV activity in the past. They are a very important component of national HIV surveillance. Further development of case reporting and availability of HIV testing will improve HIV surveillance. More intensive study of those with HIV infection, such as focus groups and/or casecontrol studies, may reveal important information about particular risk behaviors that may be targeted by prevention programs. Include other target groups in future surveys Ways should be found to target those occupational groups who were reported as making up the majority of commercial sex clients in prevention activities - government workers and businessmen. Those who have worked in high prevalence countries are at high risk of HIV and they account for the majority of known cases in Lao. Further work is needed on overcoming difficulties in identifying and surveying those populations. Female factory workers reported very low levels of sexual activity. They should therefore not be considered a high-risk group, and it Recommendations 37

43 will be difficult to measure changes in risk behavior in this population. This should be taken into consideration when deciding on target populations for future surveys. Future HIV surveillance should include monitoring the nature of sex work in Laos to ensure that changes are detected. Collect data on country of origin and country of sexual contact. This survey did not collect data on sexual contact by the participants when traveling or working in higher prevalence countries, or the nationality of the clients of service women. Future surveys should collect data on sexual contact overseas, both for service women and long distance truck drivers, and the nationality of clients in Laos. Skills development Future surveillance will benefit from increased skills and experience in collecting, analyzing and reporting surveillance data. 38 HSS and SPPS : Lao People s Democratic Republic, 2001

44 REFERENCES 1. National Committee for the Control of AIDS Bureau, Ministry of Health, Country Report on HIV/AIDS, Lao PDR, November UNAIDS/WHO. Guidelines for second generation HIV surveillance (2000). 3. National Committee for the Control of AIDS Bureau, Ministry of Health. Behavioral Surveillance Survey summary report. 4. Chin J, Bennett A, Mills S. Primary determinants of HIV prevalence in Asian- Pacific countries. AIDS 1998;12 (suppl B):S87-S Lyttleton C. Any Port in a Storm: coming to terms with HIV in Lao PDR. Cultuer, Health and Sexualty 1999;1(2): Black CM. Current methods of laboratory diagnosis of Chlamydia trachomatis infections. Clin Micro Rev 1997(10): Brunham RC, Plummer FA. STD epidemiology and its implications for control. Med Clin North Am 1990; 74: E.R. Ramos, T. Wi, R. Steen, T.A. Esguerra et al. Rapid and sustainable reductions in curable STDs among urban sex workers in the Philippines XIV Int Conf AIDS, Barcelona, July [Abstract TuOrD1152]. 9. Davies SC, Otto B, Pardohudoyo S, Chrisnadarmani VAMA, Neilsen GA, Ciaffi L, Patten J, Syamson, Sutama N. Sexually transmitted infections among female sex workers in Kupang, Indonesia: searching for a syndromic algorithm to manage cervical gonococcal and chlamydial infections. [unpublished]. 10. Rahman M, Alam A, Nessa K, Hossain A, Nahar S, Datta D, Alam Khan S, Amin Mian R, Albert MJ. Etiology of sexually transmitted infections among street-based female sex workers in Dhaka, Bangladesh. Journal of Clinical Microbiology Mar;38(3): References 39

45 40 HSS and SPPS : Lao People s Democratic Republic, 2001

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