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Preventing Syphilis among Low-Fee Chinese Sex Workers with the CHAT Intervention

Introduction
Over 1 billion people globally acquire a sexually transmitted infection every day [9]. These
infections cost health care systems billions of dollars, are increasingly drug resistant, and are
disproportionately acquired by people of color, people of lower socio-economic standing, young
people, women, sex workers, and men who have sex with men [9]. STIs can be transmitted to
congenitally as well as sexually, and have serious effects on the physical, social, and mental
health of those who are infected. One especially detrimental STI is Treponema Pallidum,
commonly known as syphilis, a curable but often latent infection with severe long term and
congenital effects [1]. A population particularly at risk for syphilis is low-fee Chinese female sex
workers (FSWs) [3, 11]. To prevent and/or treat syphilis among this population, we can
implement the CHAT intervention, a behavioral peer mentor led group counseling intervention
for high risk women and their social groups. CHAT is an acronym for the principles on which
group conversations are founded, they are, (1) Choose the right time and place; (2) Hear what the
person is saying; (3) Ask questions; and (4) Talk with respect [6].
Description of Target Population
China is currently experiencing a severe increase in the presence of STIs with gonorrhea and
syphilis rates prevalence rates increasing 3 and 200 fold respectively [4]. Female sex workers are
consistently at a higher risk for STIs than other women due to their high amount of partners and
the imbalanced power dynamics of prostitution [2, 8, 9]. The prevalence of STIs among low and
middle income Chinese FSWs in Guangdong province is 32.2% [11]. Low fee Chinese FSWs are
more likely to have injected heroin, have three or more clients a day, and work six or more days
a week when compared to middle fee Chinese FSWs [3]. Intravenous drug use increases the risk

of exposure to HIV and Hepatitis, and the increased amount of work days combined with the
increased amount of partners per day greatly increases the risk of exposure to STIs [1, 9].
Methamphetamine use among Chinese FSWs is also linked with a doubled incidence of syphilis
[10]. Because they are paid less than the average sex worker, low fee Chinese FSWs are typically
in more precarious financial situations, and are less capable to decline extra pay for condom-less
sex. Compared with 11.9% of middle fee Chinese FSWs, 48.5% of low fee Chinese FSWs will
agree to not use a condom if offered higher pay by one time clients [3]. These statistics only vary
by about 1% in cases with regular clients. Sex workers also are subject to high amounts of stigma
and are less likely to pursue or receive STI testing due to fears of discrimination and lack of
accessibility.
Description of Selected STI
Treponema Pallidum is the bacterium that causes syphilis, it is highly sensitive to its
environment and has an incubation period of 10-30 days [7]. T. Pallidum has three stages: the
primary stage consists of a painless genital ulcer, leaving the area increasingly exposed to other
pathogens, it is during this stage that syphilis is most contagious. The secondary stage is
characterized by a painful rash on the body, typically on the hands and feet. Tertiary syphilis
results in neurological complications, blindness, organ damage, and possibly death. In between
each of these stages are often periods of latency, these stages can last anywhere from a few
months to a lifetime [1, 5]. A particularly dangerous outcome of T. Pallidum is congenital
syphilis, which commonly results in birth defects and stillbirth. 40% of children born with
congenital syphilis are stillborn or die from infection as a newborn [1]. Syphilis can be difficult
to treat because the symptoms can often mimic those of other diseases [5]. Having syphilis can
also increase ones risk of acquiring HIV, and HIV positive individuals are at a greater risk of

developing neurosyphilis [1, 7]. Prevalence of syphilis among low-fee Chinese FSWs is 15% [3]
compared to the global prevalence of .48% [9]. Globally, syphilis affects over 5% of sex workers
in 34 countries including China [8].
Description of the Selected Prevention Intervention
The goal of the behavioral intervention CHAT is to lower high risk behavior and improve
HIV/STI communication abilities among high risk heterosexual women and their social groups.
The intervention consists of group behavioral counseling that incorporates peer leadership.
Groups of four to eight participants who belong to a similar social network meet for two hour
sessions, six times, over a period of three weeks. One of these meetings is an individual session.
There were two conditions for the study, the peer mentorship CHAT condition and the standard
of care condition based off of Project RESPECT. Participants then completed 6, 12, and 18
month follow up visits [6].
The population tested in the study consisted of 169 heterosexual women ages 18-55 who self
reported having at least one male sex partner in the last six months, and at least one high risk
behavior (multiple partners, intravenous drug use, unprotected sex, transactional sex, partners
with drug use or STI/HIV). The participants were randomized to the CHAT or the standard of
care condition.
The intervention significantly decreased risk behavior and was evaluated by comparing
changes in high risk behavior within both groups. After participants completed a survey, the data
showed that the CHAT group was significantly less likely to engage in risk behavior than the
comparison group. 18 months after the intervention, participants were significantly less likely to
engage in unprotected anal sex (AOR= .24, C = .09, .68, p<.01), unprotected vaginal sex (Adj O

= .47, CI= .25, .87, p<.05), unprotected sex with a main partner (AOR= .41, CI= .21, 0.77,
p<.01), and any high risk sexual behavior in the past 90 days (AOR= .30, CI= .14, .64, p<.01)
[6]. The data from the post intervention follow ups showed that these results were maintained up
to 18 months post intervention [6].
Implementing CHAT in a community of low fee sex workers in China would (if effective)
increase condom use and negotiation skills, raise awareness to STI treatment and testing
services, and increase condom use with main partners. The evaluation of CHAT did not address
changes in STI incidence, but a decrease in STI incidence can be expected because of the
changes in behavior that can result in STI occurrence. It will be worthwhile to implement CHAT
in low fee sex worker communities in China because they are such a highly stigmatized
population, and using peer mentor based counseling will likely be the most effective way to
eliminate fears of stigma and have lasting effects post intervention.
Impact of Intervention
If implemented, CHAT would likely lead to a decrease in syphilis among low-fee Chinese
FSWs. Though the CHAT evaluation did not quantify changes in STI incidence, the results
showing increased condom use, condom negotiation, and HIV/STI communication skills [7]
would lead us to expect reduced STI incidence, but will need to be evaluated.
Certain aspects of the original intervention, such as efforts to lower the number of sex partners
and reduce participation in transactional sex will likely not change in this population due to the
nature of sex work. Injection drug use was one of the risk factors that decreased during the
CHAT evaluation but because there was not specific data given for this behavior change it cannot

be certain that injection drug use will decrease as a result of CHAT. Even with improved condom
negotiation skills, FSWs will still be working in environments with severely imbalanced power
dynamics and high incidence of sexual assault, and will be at risk of forced condom-less sex.
Low-fee Chinese FSWs will also still be under significant economic stress and may be unable to
decline higher pay for condom-less sex or other higher risk sex acts.
The overall risk for syphilis among Low-fee Chinese FSWs will likely be reduced as a result of
implementing the CHAT intervention, but would still be higher than the overall risk for the
average Chinese person because of the risks specific to their work. Because the focus of CHAT is
communication and community, the STI/HIV awareness and condom use/negotiation skills
learned by participants in the intervention will be shared with their peer groups. Women who
participate in the intervention are encouraged to bring up STI/HIV knowledge and condom skills
to their friends, and the women who are trained as peer mentors will be trained in leading
discussions about sexual health and preventing risk behavior. Adjustments can be made to
discussions to better address specific issues faced by low-fee Chinese Sex workers that may not
have been addressed in the original intervention. The impacts of discussing awareness of syphilis
and showing sex workers what resources they have to get tested and treated can spread beyond
those in the intervention and potentially lower syphilis incidence.
Conclusion
Low-fee Chinese Sex workers have a prevalence of syphilis three times higher than that of the
general Chinese population [3]. Because of their lack of access to healthcare due to stigma and
low socio-economic status, they, and any children they may conceive are at risk of experiencing
the long term effects of syphilis due to lack of treatment. A preventative behavioral intervention

like CHAT can effectively communicate the risks of syphilis and other STIs and introduce
preventative measures into communities that may not have access to health information. The
communication skills and knowledge to be gained through CHAT by those in the intervention
could have significant effects on syphilis rates among Low-fee Chinese FSW communities.
References
1. CDC. Syphilis-CDC Fact Sheet. 2015. http://www.cdc.gov/std/syphilis/stdfact-syphilis.htm
2. Yi C, Zhiyong S, P MJ, Kaveh K, Zunyou W. Bridging the Epidemic: A Comprehensive
Analysis of Prevalence and Correlates of HIV, Hepatitis C, and Syphilis, and Infection among
Female Sex Workers in Guangxi Province, China. PLOS One 2015; 10.
3. H Li, C Zhu, Z Liu, et al. Differences in risk behaviours and HIV/STI prevalence between
low-fee and medium-fee female sex workers in three provinces in China. Sexually Transmitted
Infections 2015; 10.
4. Liu J, Calzavara L, Mendelsohn JB, et al. Impact evaluation of a community-based
intervention to reduce risky sexual behaviour among female sex workers in Shanghai, China.
Biomedical Central Public Health 2015; 15.
5. Rebecca L, Sheila L. Biological Basis for Syphilis. Clinical Microbiology Review 2006;
19:29-49.
6. Rothwell MAD, Tobin K, Yang C, Sun CJ, Latkin CA. Results of a randomized controlled trial
of a peer mentor HIV/STI prevention intervention for women over an 18 month follow-up.
AIDS and Behavior 2011; 15:1654-63.
7. Justin R. Medical Microbiology. In: Samuel B, ed. Treponema. Vol. 4th edition. University of
Texas Medical Branch at Galveston: University of Texas Galveston, 1996.
8. WHO. Sex Workers and Syphilis. In: WHO, ed, 2005-2013.

9. WHO. Sexually Transmitted Infections, Fact Sheet 110. Accessed December 9 2015.
10. Li Z, Li D, Liu H, Jiang Z, Zhu L, Wang N. Study on the prevalence and associated risk
factors related to HIV, syphilis, herpes simplex virus-2 among female sex workers in Jiaozhou,
Shandong province. Zhonghua Liu Xing Bing Xue Za Zhi 2014; 10:1099-104.
11. Chu Z, Kemming R, M DW, Yu W, Wei D. High Prevalence of HIV and Syphilis and
associated factors among low-fee female sex workers in mainland China. BioMed Central
Infectious diseases 2014; 14:225.

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