1. Washington D.C., USA, 22-27 July 2012www.aids2012.org Condom Attitudes of Female Entertainment Workers in Metro Manila, the Philippines: Setting, Peer Influence and Social Support Lianne A. Urada, PhD, MSW, LCSW 1 Steffanie A. Strathdee, PhD 1 Robert F. Schilling, PhD 2 Benilda de Guia 3 Donald E. Morisky, Sc.D., Sc.M., M.S.P.H. 4 1 University of California at San Diego, Division of Global Public Health, Department of Medicine 2 University of California at Los Angeles, Department of Social Welfare 3 PAMAC-Q (Peer Educator's Movement for Empowerment), Philippines 4 University of California at Los Angeles, Department of Community Health Sciences Funded by: T32 DA023356, UC Pacific Rim Research Program, UCLA International Institute

2. HIV in the Philippines HIV increased 3-fold among Female Sex Workers (2007 to 2010). Quezon City = largest suburb of Metro Manila (48% of HIV cases) 1 of 7 countries with a ≥ 25% increase in new cases in 2011 (UNAIDS, 2011).

3. Quezon City Requirements for Female Bar/Spa Workers: Health certificates HIV/AIDS seminars Weekly STI exams...is not legalized. However, Sex Work in the Philippines

4. Washington D.C., USA, 22-27 July 2012www.aids2012.org Objective/Hypotheses  To assess individual, social, and physical risk environment factors associated with condom attitudes among female bar/spa workers in Quezon City, Metro Manila. Hypotheses: More positive condom attitudes are associated with: 1)Peer and manager support for condom use 2)Social support

5. Methods Sampling, Recruitment  Bar/night club, spa/sauna, karaoke bars stratified by size and type.  Modified time-location sampling of individuals at venue/clinic: all interviewed (smaller venues with ≤10 workers) or else randomly sampled. Data collection: Interviews  Trained local NGO peer educators as interviewers.  Interviewer-administered surveys with female bar/ spa workers (N=498) from 54 venues in Quezon City, Metro Manila (2009-2010).

6. MeasuresDefinition Condom Attitudes Scale *  10-items (1-strongly agree, 5-strongly disagree) Max. possible score: 50 Drug use  How often do you take drugs (0-never, 5-always) General Social Support  Emotional, Tangible, Functional (0-not at all, 4-great deal) Max. possible score: 196 (Norbeck, 1984) Manager Support for condom use* (Yes/No)  (condom use with venue guests) Peer Support for condom use (Co-worker)* (Yes/No)  Ever discussed STI/HIV prevention  Ever tried to convince worker to use condoms with venue guests  Used condom when having sex with venue patron due to co-worker’s advice Venue Policy* (Yes/No)  Condom use rule  Condom availability for workers *Adapted from Morisky et al (2002)

7. Washington D.C., USA, 22-27 July 2012www.aids2012.org Statistical Analysis  Data analysis restricted to those having sex past 6 months (N= 356).  Hierarchical Linear Regression, adjusted for age, education, and individuals nested within venues.  Tested for plausible 2-way interactions.

8. Characteristic%, Median/IQR Individual Age (median years/IQR)22 (20-26) Education (years) (H.S. diploma=10 th grade)10 (9-11) Months worked as bar/spa worker14 (8-32) Drug use (current) (e.g. Methamphetamines)10 Alcohol use (daily)15 Consistent condom use45 Knowledge of AIDS (1-none to 5-great deal)2 (2-4) Social Risk Environment Peer support (co-workers) for condom use1 (0-3) Manager support for condom use25 General social support (not for HIV/STI prevention)79 (53-101) Physical Risk Environment Venue type - Night club/bar Spa/sauna Karaoke bar 35 49 16 Condom rule at venue29 Condom availability at venue32 Results: Socio-Behavioral Demographics, N=356*

9. Condom Attitudes (N=356) %

10. Factors Significantly Associated with More Positive Condom Attitudes, Female Bar/Spa Workers in the Philippines (N= 356) Model 1Model 2 Beta95% Confidence Intervals Beta95% Confidence Intervals Individual Drug use (inverse association) - 1.13 - 1.78, - 0.48-1.14- 1.76, - 0.52 Physical Risk Environment Work in spa/saunas vs. night club/bars 1.360.06, 2.671.26- 0.03, 2.56 Social Risk Environment Peer support (co-workers) for condom use 0.310.01, 0.63 -- Manager support for condom use -- 0.29- 0.74, 1.33 General social support -- 0.01- 0.01, 0.01 (Interaction) General social support x Manager support for condoms -- 0.030.01, 0.05 * Hierarchical Linear Regression, adjusted for individuals nested within venues, age, education

11. Model 2. Predicted Condom Attitudes for the Average Female Bar/Spa Worker Note: Data were centered by subtracting the mean value

12. Washington D.C., USA, 22-27 July 2012www.aids2012.org Limitations  Self-reported data  Cross-sectional design  Potential recall bias for measures without specific time frames  Generalizability limited to venues/individuals who agreed to participate in Quezon City (20% refused)

13. Individual  Drug use was negatively associated with condom attitudes & needs further exploration for female bar/ spa workers. Physical Risk Environment  Night club/bar workers had poorer condom attitudes than spa workers, suggesting additional intervention is needed. Social Risk Environment  Buy-in from co-workers of condom use is critical.  Efforts needed to increase social support for sex workers and manager support for condom use. Conclusions

14. Washington D.C., USA, 22-27 July 2012www.aids2012.org Implications- Next Steps Social support must be bolstered (e.g. collective action/ community mobilization) Remove macro-level structural barriers to condom use (e.g., religious opposition, funding)

15. Acknowledgements Salamat po! Philippines Team:  Benilda de Guia, Jay Caparida, & Junelyn Tabelin, Philippine Rural Reconstruction Movement, Inc., & PAMACQ (Peer Educator's Movement for Empowerment Pasay, Manila, Caloocan & Quezon City), with Ms. Joy Ferriols-Pavico, Center for Environment and Sustainable Development Foundation, Inc. (CESD)  Professor Laufred I. Hernandez, University of the Philippines Manila  Dr. Nymia Pimentel-Simbulan, University of the Philippines Manila Funding Support:  NIDA (Strathdee T32 DA023356)  University of California’s Pacific Rim Research Program  UCLA International Institute  UCLA Graduate Div. to Community Health Science Dept’s Doctoral Training in the Social & Behavioral Determinants of HIV/AIDS Prevention (Morisky) Special Thanks: Abby Rudolph, Ph.D., Tommi Gaines, Ph.D., UCSD, & the research participants!

16. References Morisky DE, Peña M, Tiglao TV, & Liu KY. The impact of the work environment on condom use among female bar workers in the Philippines. Health Education and Behavior 2002; 29: 461-472. Norbeck JS. Social Support Questionnaire. Birth Defects Original Article Series 1984; 20: 45-57. Philippines Department of Health, National Epidemiology Center. HIV/AIDS Registry Report, 2010. Rhodes T. Risk environments and drug harms: a social science for harm reduction approach. International Journal of Drug Policy 2009; 20: 193–201. Strathdee SA, Lozada R, Martinez G, Vera A, Rusch M, et al. Social and structural factors associated with HIV infection among female sex workers who inject drugs in the Mexico-US border region. PLoS ONE 2011; 6:1-8. UNAIDS. Report on the global AIDS epidemic 2011. UNODC. 2008 World Drug Report of the United Nations Office on Drugs and Crime. Urada L, Morisky D, Hernandez L, Strathdee SA. Social and structural factors associated with consistent condom use among female entertainment workers trading sex in the Philippines. AIDS and Behavior 2012 (in press). Urada LA, Morisky DE, Pimentel-Simbulan N, Silverman JG, Strathdee SA. Condom negotiations among female sex workers in the Philippines: Environmental influences. PLoS One 2012 (in press).