February 28, 2016

An HIV Prevention Success: 100% Condom Use Programme

Guest blogger Allison Yates discusses an HIV prevention campaign in Southeast Asian sex establishments called 100% Condom Use Programme.

Print More
A photo of a colorfol wheel with the text "Spin to test your luck and safety" and various outcomes on the wheel such as "-20 Syphilis (no condom)."

A photo of a colorfol wheel with the text "Spin to test your luck and safety" and various outcomes on the wheel such as "-20 Syphilis (no condom)."

In my previous post An Introduction to the World of Sex Tourism, I explained some of the consequences that sex tourism has on a community. Aside from child exploitation and economic effects, another serious consequence of sex tourism is the increased incidence of STIs and HIV/AIDS.

For example, “beach boys,” or male sex workers in the Caribbean, are less likely than female sex workers to use condoms because they don’t always perceive their work as sex work. Condom non-use is directly positively correlated with the transmission of STIs. Addressing negative consequences of sex work can be challenging, especially when sex work is illegal and sex workers and their clients keep their arrangements discrete in order to avoid arrest. In this post, I will share how southeast Asian countries, specifically Thailand and Cambodia, have worked toward addressing the public health issues that have arisen as a result of sex tourism. This campaign is called the “100% Condom Use Programme,” or “100% CUP.”

What Is The 100% CUP?

The World Health Organization (WHO) has written a report summarizing the 100% CUP, its implementation in various Asian countries, and its success. This informative source is the primary reference for this blog post unless where otherwise noted. WHO defines the 100% CUP as “a collaborative programme between local authorities (health, police/public security and Governor/Mayor’s office) and all sex entertainment establishments (owners/managers and sex workers). The aim of 100% CUP is to assure that, as you might guess, condoms are used 100% of the time and especially during risky sexual relations and in all sexual entertainment establishments.

Why Was There a Need for This Program in Southeast Asia?

The predominant avenue for transmission of HIV/AIDS globally as well as in in Asian countries is through heterosexual intercourse, although rates of HIV do tend to be higher among injecting drug users, blood product recipients, and those born to HIV positive mothers. WHO estimates that 90% of HIV cases worldwide were transmitted heterosexually. In the late 1980s, officials began to identify cases among sex workers within specific countries in southeast Asia, and as HIV sentinel surveillance systems began collecting and comparing data it was discovered that sex workers and their clients were highly contributing to the spread of the epidemic. It only took a few HIV positive clients to quickly transmit the disease to a larger community due to the nature of sex work. To provide a sense of the rate of transmission, surveys of sex workers in Thailand found that between 1989 and 1991, there was an increase from 3.1% infection rates to 15.2%. In neighboring Cambodia, the incidence of HIV among establishment sex workers was 42.5% in 1998, despite Cambodian officials providing educational materials and skills training to its sex workers.

After identifying sex workers and clients as high risk for transmission, officials in Thailand began to identify and tackle the root causes of condom non-use. The two major limitations preventing Thai female sex workers from using condoms were: 1) an economic disincentive, and 2) a power imbalance between female sex workers and male clients in a negotiation. In other words, it was economically detrimental for women to negotiate condom use; if she was persistent about using a condom, the male client could easily go to a different establishment. Using this information, Thai officials developed the first 100% CUP.

How Did The Program Aim To Promote Condom Use In Sex Work?

Understanding the socioeconomic issues sex workers faced when trying to negotiate condoms with clients, the Thai 100% CUP stipulated that all sex establishments would henceforth require use of condoms in sexual encounters with the slogan being “No condom-no sex.” This sought to remedy the issue of clients going to other sex establishments if a sex worker at one insisted on using a condom. Officials also targeted the sex establishment owners and managers. They were educated on the necessity of promoting 100% condom use and asked to publicize the new policy (some put signs in their premises) with clients and be supportive of women in negotiating condom use with clients. There were also punitive consequences, such as closures, for establishments that did not uphold the new policy.

What Was The Result Of The 100% Condom Use Programme?

Data collected by UNAIDS in Thailand, after the program’s first pilot campaign, found that there was a direct correlation between the condom use in sex establishments and the decline of STIs. Through empowering female sex workers to negotiate with clients (sex workers received insurance, self-help groups and peer education), educating owners and managers and publicizing the “No condom- no sex” policy, there was a decline in STIs and HIV among both sex workers and young Thai men.

Pilot programs were first tested in select provinces, and given success expanded to other parts of each country. After positive results the program expanded nationwide in Thailand in 1991 and later nationwide in Cambodia in 1999, where it had exceptional results. After these success stories, the program was expanded to China, Laos PDR, Mongolia, Myanmar, the Philippines and Vietnam. Recent data reflecting the effectiveness of the 100% CUP was found for China and Laos PDR. A 2013 study by Zhang and colleagues has revealed that the HIV prevalence among female sex workers in China has stabilized at low levels and was 0.36% in 2010. A 2015 study by Andrews and colleagues found that condoms were used consistently 97% of the time with non-regular partners by female sex workers in Laos PDR. The dramatic increase in condom use and decline in STI and HIV rates across countries has demonstrated the malleability and effectiveness of this program across cultural contexts.

What Implications Does This Have For Other Sex Tourism Hotspots?

This program challenges typical assumptions about the rights of sex workers, while neither encouraging nor discouraging sex work. Moreover, empowering sex workers in many sex tourism hotspots isn’t a simple task, as many of them are treated in a degrading way due to their line of work. That being said, this program has great potential to be successfully applied outside of southeast Asia.

In order for the campaign to be successful, there must be collaboration between all involved parties. With the 100% CUP, promoting 100% condom use in all sexual encounters was the responsibility of the government officials, owners and managers of sex establishments, male clients and sex workers as well as those that had close ties with sex workers, such as NGOs. Especially with the necessity of cheap and reliable condoms for vulnerable populations, local government support is critical.

The WHO explains that there is no “one size fits all” regarding implementation of 100% CUP, although there are certain strategies that encourage the program’s success. These include starting locally at the province or city level and ensuring political support. Logistical questions regarding how condoms are made available and how sex workers and managers are trained may differ based on location. When paired with other HIV/AIDS prevention campaigns and with the support of local officials, the 100% CUP can have remarkable results on condom use and disease incidence.

There Is Still More Progress To Be Made

As the result of the 100% Condom Programme, southeast Asian countries have significantly increased the amount of sex workers who use condoms with their clients (up to 90%) and reduced the rate of new HIV cases. Still there are challenges to the program, including how to address freelance sex workers and other entertainment workers (nightclub, massage parlor, or casino employees) who do not claim to be sex workers but may engage in sex work. For instance, in Cambodia, UNAIDS is taking steps to work with locals to ensure that these workers are still receiving education and access to health services. Moreover, WHO estimated in 2010 that there were 3.5 milllion people living with HIV/AIDS in the Southeast Asia region. Further collaboration and preventative measures are still needed.

Allison Yates received a B.A. from Indiana University in International Studies. She is interested in researching cross-cultural relationships, sexual education, and violence prevention.