The Link Between STDs and AIDS

Other sexually transmitted diseases make it easier for HIV to pass from one person to another. Chancroid, chlamydia, gonorrhea, syphilis, and trichomoniasis may increase the risk of HIV transmission by two to nine times (46, 55, 105, 147, 149, 152, 234, 263, 275, 312). The link between HIV infection and other STDs may partly explain why HIV in heterosexual populations is more prevalent in Africa than in Europe and the US, where STDs are more often treated and cured (46).

Carried in body fluids, HIV may leave one person's body and enter another's more easily through genital ulcers. HIV itself has been isolated from the genital ulcers of women with HIV infection (146). Thus the link is clearest between HIV infection and STDs that cause genital ulcers, although not all studies find an association. Six of 10 studies in Kenya and Zaire, for example, found that people with genital ulcers, caused mainly by chancroid, were more likely to be infected with HIV than people without ulcers. Their risk was two to five times greater. Nine of 11 studies of syphilis and HIV infection found an association. Syphilis increased the risk of HIV infection threefold to ninefold for heterosexual men. Three of six studies of genital herpes and HIV infection found an association. Herpes doubled the risk of HIV infection for women and heterosexual men (312).

Six studies found that chlamydia, gonorrhea, and trichomoniasis, which do not cause ulcers, increase the risk of HIV transmission to women by three to five times (312). Several studies, however, have found no link between these STDs and HIV infection, but methodological problems may have obscured the connection. These STDs may enhance HIV transmission because they increase the number of white blood cells—which are both targets and sources of HIV—in the genital tract and because genital inflammation may cause microscopic cuts that can allow HIV to enter the body. Diseases causing vaginal and urethral inflammation are far more common than genital ulcer diseases and so may be responsible for a larger share of HIV transmission.

Infection with HIV also affects the other STDs. In people with HIV infection other STDs may be more resistant to treatment. For example, several studies have reported that one-dose treatment for chancroid failed at least six times more often in HIV-infected patients than in patients without HIV infection (45, 173). Also, syphilis lesions may last longer in people infected with HIV, and these people may get gonorrhea more often (312). Thus HIV enhances its own transmission: With longer-lasting STD symptoms, people with HIV infection are more likely to transmit HIV and increase the pace of the AIDS epidemic.

What Must Programs Do?

• Develop overall strategies to provide STD services based on health care resources and disease prevalence patterns.
• Combine AIDS and other STD programs.
• Get effective services to patients in primary health clinics, where people first seek care.
• Train and equip STD service providers to diagnose and treat patients in one visit.
• Ensure that primary health clinics have a reliable supply of drugs to treat STDs and a reliable supply of condoms.
• Make good counseling a high priority in STD services.
• Strengthen STD training in medical, midwifery, nursing, and other health professional schools.
• Provide in-service STD training for primary health care providers.
• Involve private practitioners—pharmacists, private doctors, midwives, traditional practitioners, and traditional birth attendants.
• Conduct mass-media campaigns and in-clinic programs to encourage people to recognize STDs, to seek treatment, to use condoms, and to have only one sexual partner.
• Conduct surveillance to identify the most prevalent STDs and the drug-resistance of STDs, especially gonorrhea.
• Set up syphilis screening programs in antenatal clinics.
• Set up special programs for high-risk populations, especially prostitutes, truck drivers, the military, and youth.
• Make sure that the sexual partners of STD patients get treated. Unless STD screening takes place, this is the only way to find and treat women with asymptomatic STDs.

The Syndromic Approach

Syndromic diagnosis is not new. Many providers in developed countries use syndromic diagnosis because they do not want to wait several days for the results of laboratory tests before they treat STD patients.

Syndromic diagnosis has several important benefits:

• It improves clinical diagnosis by avoiding wrong diagnoses and ineffective treatment.
• It can be learned by primary health care workers—clinical officers, medical assistants, nurses, or nurse-midwives. Primary care providers in Botswana, Nigeria, Tanzania, and Zimbabwe, for example, use syndromic diagnosis (126, 317).
• It allows treatment of symptomatic patients in one visit. Currently, patients may have to visit several locations. In Côte d'Ivoire, for example, patients may have to visit a clinic, a lab for tests, the clinic again for diagnosis and prescription, a pharmacy to buy the drug, and then another site for an injection (198). Some may not make all these visits, and they return home without treatment.

• Failure to care adequately for people with STDs who have no symptoms. Women with STDs are often asymptomatic.
• Wasting drugs, which are scarce in many developing countries, on treatment for STDs that patients do not actually have.

WHO is planning to compare the effectiveness of syndromic diagnosis with clinical and laboratory diagnosis in several developing countries (126). A theoretical comparison of the cost-effectiveness of the three approaches to diagnose 500 patients with genital ulcer, 500 with urethral discharge, and 500 with vaginal discharge found that clinical and laboratory diagnoses each cost two to three times as much as syndromic diagnosis. The costs of personnel and treating complications after incorrect diagnosis accounted for most of the difference. The analysis assumed that laboratory and clinical diagnosis can be performed only by physicians and that false negative laboratory tests or mistaken clinical judgments result in complications that require treatment. By treating for all STDs that cause a syndrome, syndromic diagnosis avoids many complications (125).

Improving Care for Women with STDs

STD programs can take a number of steps to provide services for women, to get women to use services, and to enable women to protect themselves against unsafe sexual relationships:

Providing Services for Women

• Conduct surveys to identify the level of asymptomatic, unrecognized, or untreated infection in women. Such surveys may reveal high levels of infection and point out the need for more funding of clinical services.
• Make clinics hospitable to women. For example, women may feel most comfortable being treated by a woman. STD programs should recruit and train women to be STD service providers. Providing a private place in the clinic for examination and discussion also is important.
• Diagnose and treat women in one visit. When asked to return for test results, many women—like men—may not come back.
• Offer sensitive and helpful counseling. Women may need help to follow the main counseling messages. In particular, many women need help to discuss STDs with their sexual partners, to persuade them to seek treatment, and to negotiate condom use.

Getting Women to Services

• Provide services where women seek care—in antenatal and family planning clinics, especially—and conduct communication campaigns to encourage women to use these clinics (see Chapter 6, Getting People to Services). If clinics cannot diagnose and treat STDs, at least they should examine women and refer infected women to STD clinics.
• Conduct educational campaigns for women about STDs. Such campaigns can provide information—on transmission, symptoms, risks to the fetus and infant, and prevention—and encourage women to seek care. Women should be aware that they can have asymptomatic STDs.
• Cover sexuality in the training curricula for health care providers, and train them to be able to discuss sexuality.

Enabling Women to Protect Themselves

• Support programs that give women more power in their relationships with men. Such power can come from financial independence, family support, and community organizing. For example, in Nigeria some Yoruba women have been able to refuse sexual relations with husbands who have STDs because they are financially independent and they can return to their families if they quarrel with their husbands. In some parts of India women have organized to stop alcoholism among men, and in Peru, to stop wife-abuse (78).
• Foster communication between men and women about sex. Small group discussions between men and women can correct misperceptions. For example, in areas of Zaire many men and women prefer to have dry and tight sex, and women often use leaves or powders to dry the vagina (39). In group discussions, however, some men and women admit that they do not enjoy dry sex. They may continue to have it, however, thinking that their partners enjoy it (140). Dry sex can increase the risk of STD transmission; the leaves and powders may irritate the vagina, and the friction of dry sex may cause small cuts in the vagina (39). Also, in small mixed groups in Zimbabwe and Ghana, men and women have confronted each other about infidelity (102).
• Educate men about STDs. Some programs have counseled men where they work or socialize. They have promoted condom use, encouraged men to talk to sexual partners about safe sex, and discussed drinking and sex (51, 103).

Family Planning and STDs: How Do They Mix?

What more should family planning programs do? Should they ask clients about symptoms and refer them to another facility for diagnosis and treatment? Should they screen all clients for STDs and refer for diagnosis and treatment? Should they also provide treatment—for one, two, or more STDs? Assessing clients' needs—through screening studies and focus-group discussions, for example—can help programs learn what is needed. Of course, the appropriate level of STD services also depends on resources, including the drug supply.

Programs are trying a variety of approaches. Affiliates of the International Planned Parenthood Federation (IPPF) in Africa and Latin America, for example, typically provide some counseling for symptomatic clients and refer them to a government clinic for diagnosis and treatment (103, 250). A number of programs diagnose and treat some but not all STDs. For example, the Gambia Family Planning Association treats women with candidiasis and trichomoniasis but refers all other women with STDs to government clinics (280). A few programs provide complete services. The Asociación Demográfica Salvadoreña (ADS), for example, screens family planning clients, treats patients, provides community outreach, distributes condoms, and notifies partners (5). In the US most family planning clinics screen clients for STDs, particularly gonorrhea and syphilis, and many both diagnose and treat STDs (2, 77, 111, 172, 235, 284). A 1990 survey of about 400 US family planning clinics found, for example, that almost all clinics screened clients for gonorrhea at the initial visit, annual visit, or when clients had symptoms, and 82% treated gonorrhea. Almost half screened for syphilis at the initial visit and treated syphilis. Almost all told infected clients to notify partners, and about one-third used staff or clinic resources to notify partners (284).

Why Strengthen STD Services?

• To serve the many people who seek care for STDs. Family planning programs in Colombia, Guatemala, the US, and other countries report that many of their clients seek treatment for STDs (10, 268, 300, 311). Staff do not want to tell patients with STDs that they cannot help (13).
• To combat high levels of STDs and reproductive tract infections in the population served (5, 72). In Guatemala staff of the Asociación Pro Bienestar de la Familia (APROFAM) screened clients in 1991-92 and found that 43% had genital ulcers or candidiasis (5).
• To prevent infertility. Family planning programs are concerned with a woman's total reproductive health and so want to prevent infertility.
• To avoid referrals that mean some clients miss care. Since clients who are referred elsewhere may not go, family planning programs that treat STDs in their clients can make sure that the infections are treated.
• To help reduce the transmission of HIV. This is one reason that ADS has set up STD services at the PROFAMILIA family planning clinic in San Salvador, El Salvador (5).
• To help women take more control over their sexual relationships. For example, women who visit the Planned Parenthood Association of Zambia fill out a questionnaire that asks about their relationship with their husbands, many of whom have extramarital sex. In small groups the women discuss how to approach the problem and rehearse dialogues that they can have with their husbands. Also, mixed groups of men and women discuss condoms and monogamy. In Guatemala APROFAM helps women deal with drinking and violence in their sexual relationships (103).
• To make money. Some family planning programs can charge for STD services. PROFAMILIA in Colombia, for example, charged about US$5.50 in 1991 for an STD consultation plus charges for diagnostic tests. The revenue from these and other gynecological and medical services helps to pay for family planning services (299).
• To serve a common clientele. Both family planning and STD programs serve a young and sexually active population. Family planning programs serve mainly women, who suffer more than men from the consequences of both unplanned pregnancy and STDs (49).
• To make use of community-based outreach. Family planning programs in The Gambia, Kenya, and other countries train community-based distributors to inform clients about STDs, to recognize signs and symptoms, and to refer people who may have STDs for treatment (93, 103, 136). In an innovative program in Matlab, Bangladesh, Lady Family Planning Visitors have been trained to perform abdominal, bimanual, and speculum exams and to take specimens for laboratory testing from women with symptomatic STDs (314). CBD workers also can give educational talks to community groups.

Drawbacks

• Less time for family planning services. Unless more personnel are hired, staff have more to do, and clients may have to wait longer. Also, to offer STD services, family planning providers need more initial training and periodic updates. A US study recorded the additional time needed to provide services for gonorrheal and chlamydial infection at a family planning clinic. The clinic screened 364 family planning clients for STDs with laboratory tests, provided services for people who came to the clinic with STD symptoms, treated and counseled women with STDs, and followed up patients to ensure that they were cured. The clinic coordinator, nurse, clerk, and physician together spent almost two hours per client to provide some or all of these services. The nurse alone spent almost one hour per STD client. Of the 364 clients receiving STD services, 85 had one or both STDs (23).
• Additional costs. In the US study, adding these services for chlamydia and gonorrhea cost about $6,000 for three months, or 14% of the total operating expenses of the clinic (23).
• Differences in counseling. Family planning providers help clients choose a contraceptive, while providers of STD services need to direct clients to treat their disease, to avoid infecting others, and to stay cured. Combining these nondirective and directive approaches to counseling may be difficult (49).
• Difficulty of treating sexual partners. Men may be reluctant to go to a family planning clinic for treatment of STDs. Thus programs may waste time and resources treating women who are then reinfected by their partners.
• Reluctance to talk about sexuality. STD service providers need to discuss sexuality. Ironically, many family planning providers are not trained to discuss sexuality and often neglect to discuss sexuality when they help clients to choose a contraceptive (131, 184, 207).
• Possible stigma of STD services. Some staff at PROFAMILIA in Colombia were worried that the stigma of STD services would spread to family planning services, but demand for family planning has not declined since 1988, when STD services were started (300). In contrast, another Latin American family planning association offers STD services in a separate clinic that is not obviously connected with the family planning clinic (250).

Contraceptives and Sexually Transmitted Diseases

Some women are not able to persuade their partners to use condoms. What then? Some argue for more emphasis on methods that women control: spermicides, diaphragm, cervical cap, contraceptive sponge, or, as it becomes available, the female condom (a polyurethane or latex sheath that a woman can insert into her vagina before having sexual intercourse). Some studies have found that in practice the diaphragm and sponge actually provide more protection against STDs or their sequelae than condoms, probably because they are used more regularly (260). Others, however, argue that there is too little evidence that spermicides and female barrier methods prevent STD transmission as well as condoms do. They also are concerned about reports of vaginal irritation caused by frequent spermicide use (that is, several times a day) among commercial sex workers. Such irritation can increase the risk of HIV transmission (48). Used less frequently, however, spermicides may not cause vaginal irritation. More research is needed on (1) contraceptive methods that women control and that protect completely against STDs; (2) methods that allow women to become pregnant and still protect them against STDs—for example, a microbicide that kills STD pathogens but not sperm; and (3) couples' willingness to use condoms and another contraceptive method at the same time.

Family planning providers, like STD service providers, need to counsel clients about STDs and stress that condoms and possibly spermicides can protect them. All family planning clients at risk for STDs, regardless of their contraceptive choice, should leave a family planning clinic knowing how to use condoms and where to get them—and, preferably, with some condoms in hand.

Resource Materials on Sexually Transmitted Diseases

Sexually Transmitted Diseases: Treatment Guidelines. US CDC, September 1989. 38 p. Available in English and Spanish. Revised English version to be available in late 1993. US Department of Health and Human Services, Public Health Service, US CDC, Atlanta, Georgia 30333, USA. Guidelines focus on treatment and counseling of individual patients, with brief mention of clinical and laboratory diagnosis when appropriate in the context of treatment. Designed for US practitioners but also useful in developing countries.

Genital Tract Infection Guidelines for Family Planning Service Programs. The Johns Hopkins Program for International Education in Reproductive Health (JHPIEGO), 1991. 143 p. Available in English and French. US$6. Revised edition available in late 1993. JHPIEGO Corporation, Materials Control Division, Brown's Wharf, 1615 Thames Street, Suite 200, Baltimore, MD 21231, USA. A primary reference for clinicians learning to diagnose and manage STDs frequently encountered in the family planning setting. Includes guidelines for client histories and physical exams, diagnostic techniques and laboratory tests, standardized treatment schedules, and flow charts and illustrations.

GTI Teaching Slide Set. JHPIEGO, 1991. Available in English and French. JHPIEGO Corporation, Materials Control Division, Brown's Wharf, 1615 Thames Street, Suite 200, Baltimore, MD 21231, USA. Consists of 104 35-mm slides on three topics: gross and microscopic lesions; diagnosis of trichomoniasis, candidiasis, and bacterial vaginosis; and diagnosis of gonorrhea.

A Practical Manual on Sexually Transmitted Diseases for the Caribbean. Revised Version. Caribbean Epidemiology Centre (CAREC), Pan American Health Organization, and World Health Organization, 1992. 118 p. US$10, $6 to students, free to STD service providers in the Caribbean. CAREC, Box 164, Federation Park, Port of Spain, Republic of Trinidad and Tobago. Guide to a systematic approach to STD management and a quick reference for the busy clinician.

The Practitioner's Handbook for the Management of STDs. Stamm, W.E., Kaetz, S.M, Beirne, M.B, and Ashman, J.A., June 1988. 117 p. US$29.50, US$7.50 additional shipping costs for developing countries. University of Washington, Health Sciences Center for Educational Resources, Distribution, SB-56, Seattle, Washington 98915, USA. A self-guided instruction manual in a 3-ring binder with graphic presentation of flow charts, tables, laboratory methods, and diagnostic tests.

Counselling and Sexuality: A Training Resource. AIDS Prevention Unit, International Planned Parenthood Federation (IPPF), 1992. Four videos and a 140-page guide. Guide may be purchased alone for US$10. Videos available separately or as a set; each video comes with a copy of the guide. US$35 for each video or $100 for the set. Video formats: English—PAL/NTSC; Arabic—PAL. IPPF Distribution Unit, P.O. Box 759, Inner Circle, Regent's Park, London NW1 4LQ, United Kingdom. Designed to help extend counseling programs from covering just contraceptive methods to covering the broader area of sexuality. Includes activities for educating providers about sexuality; guidelines and skills for counseling clients on sexuality, STDs, and sexual problems; and exploration of related policy and management concerns. One of the videos, entitled "I've Got Gonorrhea," depicts counseling a couple in which the woman has contracted gonorrhea from her husband.

Recommendations for the Management of Sexually Transmitted Diseases. WHO. To be published in late 1993. WHO, 1211 Geneva 27, Switzerland. Comprehensive guidelines for the management of the most commonly encountered syndromes, including those due to chancroid, syphilis, gonorrhea, chlamydia, trichomoniasis, and candidiasis. Also includes management of STDs in the HIV-infected patient.

Reference Materials

Color Atlas and Synopsis of Sexually Transmitted Diseases. H. Hunter Handsfield. New York, McGraw-Hill, Health Professions Division, 1992. 203 p., 136 full-color photographs. US$35 in the US; availability and prices vary in developing countries. McGraw-Hill Publications, Princeton-Hightstown Road, Hightstown, New Jersey 08520, USA. Includes case studies, an overview of STDs, summary diagnosis and management of common, uncommon, and life-threatening STDs and syndromes, information on management of patients' sex partners, and a clinical summary for each photograph.

Laboratory Methods for the Diagnosis of Sexually Transmitted Diseases. 2nd ed. Wentworth, B.B., Judson, F.N., and Gilchrist, M.J.R., eds. American Public Health Association (APHA), 1991. 339 p. US$40 plus US$10 shipping outside the US. APHA, 1015 Fifteenth Street, NW, Washington, DC 20005, USA. A practical guide for the diagnosis of STDs, useful in both clinical and laboratory settings. Provides detailed descriptions of the many different methods and types of diagnostic tests, both old and new, for most STDs, including syphilis, gonorrhea, herpes, genital warts, hepatitis, and HIV infection. Designed for US practitioners but useful in developing countries.

Patient Education

American College of Obstetricians and Gynecologists (ACOG) Patient Education pamphlets. ACOG Distribution Center, Box 4500, Kearneysville, WV 25430 4500, USA.US$15 per pack of 50 pamphlets; postage is $2 per $25 order. Pamphlets on genital warts, pelvic inflammatory disease, and STD prevention.

Formed in 1990 by an international group of STD experts, the STD Diagnostics Initiative is working to identify or develop rapid and accurate diagnostic methods and to introduce them into STD control programs. The initiative is funded primarily by the United States Agency for International Development. Other donors include the Rockefeller Foundation, the United States Centers for Disease Control and Prevention (US CDC), and the United States National Institutes of Health (274).

The initiative currently has three working groups—for chlamydia, for gonorrhea and syphilis, and for syndromicdiagnosis (242). For detecting chlamydia there are currently about 20 kits that do not require culturing a sample. The chlamydia working group has collaborated with the US CDC to evaluate some of the kits for stability, reproducibility, and accuracy. It also is surveying manufacturers on bulk purchase policies and prices (285). The working group for gonorrhea and syphilis is testing a field culture method for detecting gonococcal infection, especially cervicitis, and a finger-stick method for syphilis screening (308). On behalf of the working group for syndromic diagnosis, the Program for Appropriate Technology in Health is evaluating a method of detecting gonorrhea quickly. A sample of urethral discharge is applied to strips that turn purple within a minute if Neisseria gonorrhoeae is present (287, 293, 308).

Outreach to High-Risk Populations ...

Treating and preventing STDs in high-risk populations, particularly prostitutes, has been a standard strategy for the control of STDs (233). Recently, this strategy has become controversial. When directed at prostitutes, such an approach may seem to blame them for an STD epidemic. Focusing on high-risk populations also may divert attention from preventive information and services for the general population (228).

Focusing on high-risk populations has been effective in some circumstances, however. For example, outbreaks of chancroid in North America have been contained by treating prostitutes and their sexual partners (31, 129, 303). Also, once an STD has spread into secondary risk populations, treating STDs among high-risk populations can prevent many more new cases than treating STDs in the secondary risk populations. One projection found, for example, that treating 100 cases of gonorrhea in a high-risk population would prevent over 4,000 cases in secondary risk populations in 10 years, whereas treating 100 cases in the secondary risk populations would prevent only 426 cases (215).

Most programs for high-risk populations focus on prostitutes. A 1991 review of 83 AIDS prevention programs focusing on high-risk populations in 38 developing countries, conducted by the WHO Global Program on AIDS (WHO/GPA), found that 50 worked only with prostitutes. Twenty-eight worked with both prostitutes and clients or else with clients alone, mainly truck drivers and the military (83).

Outreach to Prostitutes

Baseline research helps to identify the specific groups a program is trying to reach and to design appropriate messages. Research can identify the different types of prostitutes in an area, where they work, and whether they are independent or managed by a pimp, madame, or hotel manager. Research also can identify whom prostitutes trust. In a program in Bulawayo, Zimbabwe, for example, baseline research found that prostitutes trusted hotel security staff. As a result the program trained the security staff to counsel the prostitutes (158). Also, research can elicit prostitutes' and clients' opinions about condoms, in what situations they use them, and what inhibits condom use (158).

Programs have treated prostitutes in clinics located where prostitutes live or socialize. This has been done in the Dominican Republic, Kenya, Nigeria, Scotland, and elsewhere (44, 81, 206, 339). Also, programs have arranged for a doctor or nurse to care for prostitutes where they work, as has been done in India, Nigeria, and Tanzania (104, 182, 237). Some governments—in Bolivia, Djibouti, Greece, Thailand, and the Philippines, for example—require registered prostitutes to attend clinics periodically for testing and treatment (32, 195, 217, 254, 297).

Educational activities explain what STDs are, stress prostitutes' risk of infection, and promote condom use. Counseling messages include:

• STDs, including HIV, are common among prostitutes.
• If you are not infected now, you still may easily become infected.
• You can easily infect clients.
• Having another STD increases your chances of being infected with HIV.
• Do not have sex if you have genital sores, rashes, or discharge, and seek treatment immediately.
• Use condoms if possible with clients and steady partners.
• Injecting heroin or other drugs with used needles can transmit HIV.

Prostitutes counsel other prostitutes in many AIDS and STD prevention programs. Current or former prostitutes who are trained in STD prevention can have more influence on other prostitutes than outsiders (57), and they can reach prostitutes more easily. Between 1987 and 1991 about 600 peers counseled about 21,000 prostitutes in 28 projects supported by AIDSTECH, a 5-year project funded by the United States Agency for International Development and managed by Family Health International (84).

Evaluating peer counseling is difficult because it is usually one of several components in outreach programs. One study in Nairobi, Kenya, found that 80% of prostitutes who had individual peer counseling and attended community education meetings reported some condom use. By comparison, 70% of prostitutes who only attended community education meetings reported some condom use. The program also provided STD and HIV testing, STD treatment, and free condoms (206).

Some programs are helping prostitutes to find other work. In the Philippines, for example, the private nonprofit organization Third World Movement Against the Exploitation of Women trains prostitutes in dressmaking, typing, and computer operation (32).

Promoting condoms in commercial sex is difficult because most clients prefer sex without a condom. In addition to interpersonal counseling and other educational approaches, programs have worked with brothels or prostitutes' organizations. For example:

• In Thailand staff of the Family Planning Unit of the Faculty of Medicine at Khon Kaen University promoted a condom-only policy in 22 brothels in 1990 and 1991. They educated brothel managers about AIDS, encouraged them to refuse service to clients who will not use condoms, and gave them condoms once a month. On average in all 22 brothels prostitutes used condoms in over 90% of sex acts. The prevalence of syphilis among prostitutes declined from 6% to 2% between December 1990 and March 1991 (266). Such condom promotion programs need government support. The Thai Ministry of Health has established a "100% Condom Program" that threatens to close brothels unless they refuse service to clients who will not use condoms (251).
• The Association of Prostitutes of Vila Mimosa in Rio de Janiero, established in 1987, set up a program that included STD and AIDS education and condom distribution. Only 2% of prostitutes reported in 1988 that they sometimes used condoms, but in 1991 some 48% of prostitutes surveyed said that they always used condoms. In fact, 84% said that they wanted to use condoms, but some could not because of a shortage of condoms in the area (56).

Outreach to Prostitutes' Clients

In areas where prostitutes work, programs have:

• Displayed posters or distributed pamphlets in brothels, movie theaters, bars, restaurants, and shops, as in Australia and India (90, 238, 245);
• Set up a clinic for prostitutes' clients, as in Kenya (43).
• Sponsored entertainment featuring STD prevention messages, as in the Dominican Republic and India. In a program in Bombay, India, street theater has attracted large crowds of clients and prostitutes. The program also sponsored a popular film in a theater and interrupted it at several points to present information about AIDS and other STDs (238, 245).

• Counseling based on surveys of attitudes and practices. For example, staff of the AIDS Research Foundation of India (ARFI) surveyed truck drivers at STD clinics. They found that the drivers believe that they need sex to dissipate heat that builds up in their bodies from the trucks' engines. Counselors suggest that drivers use condoms to catch the heat that they need to dissipate. The Foundation plans to record songs on tape cassettes that urge truckers to be safe on the road and at the truck stop. The tape cassettes will be played in tea shops at the truck stops. Also, ARFI distributes a poster in which, for the first time in India, a doctor promotes condoms to prevent both pregnancy and STDs (246).
• A physical exam and/or STD testing and treatment. For example, a pilot program for recruits to the Royal Thai Army included a physical exam, medical and sexual history-taking, and tests for syphilis and HIV (127).
• Condom distribution. In a program in Tanzania sponsored by the African Medical Research Foundation (AMREF), nearly 750 peer educators, mostly prostitutes, have distributed more than 3 million condoms to 27,000 truck drivers and prostitutes since 1990 (63). Two major trucking companies have allowed AMREF to set up condom dispensers in their offices (84).

• Focus on both prostitutes and clients,
• Involve prostitutes and clients in design and implementation, and
• Promote condom use and make inexpensive condoms available, often in social marketing programs (6, 83).