100% Condom Program Preventing AIDS Transmission in Wuhan City

——Hubei Provincial Administrative Office of 100% Condom Program Applicable to Recreation Areas

Wuhan Centers for Disease Prevention & Control

In 2001, Ministry of Public Health implemented the 100% Condom Program in four experimental areas in Huangpi District, Wuhan City, Hubei Province, Jingjiang City, Jiangsu Province, Danzhou City, Hainan Province and Lixian City in Hunan Province in cooperation with WTO. 100% Condom Program is both a policy and action. In other words, it means that it is necessary to advocate the 100% condom use among female sex workers and clients in 100% recreation places in communities for 100% working time. The purpose of implementing of 100% condom use is to reduce the risk of STIs and AIDS among female sex workers in recreation places, bring down number and proportion of populations exposed to STIs and AIDS, and thereby effectively control the transmission of STIs and AIDS among female sex workers in recreation places, clients and common people.
——Editor

Ever since the first case of HIV infection was discovered in 1988, the accumulated number of diagnosed HIV infection in Hubei Province had increased to 1301 by the end of December 2003. The existence of commercial sex transaction as well as its diversified forms has fueled the transmission of AIDS.  Most of illegal sexual behaviors are concentrated in recreation places. The poor consciousness of self-protection of female sex workers as well as the low rate of condom use has made the sexual transmission become one of the major route for the HIV/AIDS transmission.

The promotion of condom use in recreation places was beyond imagination several years ago. However, experience of pilot area in Wuhan City indicates that the promotion of 100%condom use in recreation places can effectively prevent the transmission of AIDS. So far, this mode has been widely accepted in Hubei Province.

1. A Special Survey

In 2000，leading officials from Health Bureau of Hubei Province and Wuhan Municipal Health Bureau went to Thailand and Cambodia to investigate preventions of AIDS. Although prostitution and whoring are illegal in the two countries, they began to promote the condom use in recreation places at early stages, and have obtained satisfactory effect. During the study toure, chief of Disease Control Section of Wuhan Municipal Health Bureau and officials in charge of 100% Condom Program in recreation places in Huangpi District, Wuhan City observed for the first time the 100% Condom Program in a close range.

It was beyond imagination in eyes of Chinese people to promote the condom use in recreation places at that time. Many people would inevitably think of the same question: if this action permits the legality of prostitution and whoring? With this question in mind, members of investigation group took their trips. Upon the completion of the toure, relevant official from Huangpi District made the following statements:

“The advocacy board for promotion of use condoms can be seen each recreation places in local regions (Thailand and Cambodia). In addition to the dissemination of knowledge on the prevention of AIDS among the high risk population as organized by government staff, many volunteers from nongovernmental organization devote themselves to this activity". This kind of situation is quite out of our expectations. We have never imagined that they can do the job of dissemination of knowledge on AIDS prevention in such an effective way. Furthermore, the promotion of condom use in recreation places is widely accepted by people”.

It is learned from the investigation that the current situation of condom use  in recreation places in Thailand is quite different  from the past. The rate of condom use has increased from previous 14% to 95.5% at present. The annual incidence of HIV has decreased from previous 400,000 to 14,000 at present. At the same time, the transmission of AIDS as well as the deluge of sexual transaction has also been brought under control in Thailand and Cambodia. Thus it can be seen that it is necessary and important to promote the condom use.

2. Troublesome Site Selection

Condom promotion starts from study tour firstly, and site selection secondly. In November, 2001, WTO decided to designate Wuhan as a pilot area for the promotion of use condoms through investigation. At that time, it was still a sensitive thing to distribute condoms in recreation places. In view of this factor, working staff did a great deal of work in advance, and selected suburbs where recreation places were concentrated for pilot promotion of condom use. Caidian and Huangpi districts were selected as the backup areas. After that, such problems and doubts as side effect of “condom, prostitution and whoring as well as prevention of AIDS” came on in succession. According to one official from Caidian District Government, he was in favor of the implementation of 100% Condom Program himself. The only problem was the great difficulty in promoting the condom use.

Knowing this kind of situations, Wuhan Municipal Health Bureau was of the opinion that the experiments in selected places would have very important effect and significance on the promotion of condom use in Wuhan as a whole despite of the difficulties in implementing the 100% Condom Program currently. This job must be carried on despite of so much difficulties and resistances in promotion the condom use. Nevertheless, officials from Huangpi District assumed this job, and selected Mulan Scenic Spot in Huangpi District as the final site. 

3. Desensitization by Condom Blowing

Shortly after the Spring Festival in 2001, Disease Control Center of Huangpi District established the working group consisting of 4 members for the purpose of taking charge of the pilot work. However, the “desensitization of condom” was till the problem bothering the working group. Even families of members of the working group thought it was incomprehensive. 

How to drive away this “lion in the way”?

In an attempt to further improve the work efficiency, WTO carried out timely training for members of the working group. The whole training was started from the “desensitization”. Members of the working group were requested to talk more about “condom”, the formerly embarrassing word, and were even requested to blow the “condom “as the balloon. At the very beginning, this kind of “alternative” desensitization training astonished members of the working group. However, with the further study, everybody became adapted to it, and the blowing of condom gradually became an episode for the regulation of study atmosphere. For instances, anyone who failed to answer a given question correctly would be requested to blow several “balloon” as penalty.  

Later, everybody realized that the most important thing was to control the sexual transmission of AIDS in recreation places rather than whether the condom issue was sensitive or not.

4. Whether it is necessary to ban the prostitution and whoring or not

Although disease control sectors became convinced at this issue, it was still very difficult for staff from relevant sectors to understand the 100% Condom Program. Staffs from public security sectors felt more perplexed about it. How about issue of prostitution and whoring if we are requested to coordinate with health bureau in promoting the condom use in recreation places?

 “Just as the fastening of seat belt is far from being encouraging drivers to incur accident, the promotion of condom use is also far from being encouraging prostitution and whoring”. Leading officials of the working group communicated with Public Security Section of Wuhan Municipal Public Security Bureau and Huangpi Public Security Office for many times by citing this instance.

The Policy Initiative Forum presented by numerous sectors was held in April, 2001. This kind of communication was very important at that time. Without the supports from local public security department, it would be impossible for the implementation of this program. As described by captain of Public Security Brigade of Huangpi District Public Security Office latter, it was improper to equal the condom and sexual transaction. Definition of sexual transaction should satisfy certain conditions, including specific population, specific place and specific behavior.

In an attempt to minimize the susceptibility, Wuhan Municipal Health Bureau adopted the uniform saying of “AIDS Prevention Program in Wuhan City” when communicating with Wuhan Municipal Public Security Bureau without mentioning condoms. The formal name of the program was not disclosed until June 2001 when the agreement was reached between both parties through communications.

5. Establishment of “Red-light District Makes No Sense

During the policy initiative conference held on April 9, 2001 at Mulan Lake, more than ten officials, including deputy chief of Wuhan Municipal Public Security Bureau and deputy director of Huangpi District had informal discussion with bosses from recreation places for two consecutive days. This informal discussion was regarded as a conference of innovative significance by the working group of the program. 

“It is the first time for us to discuss with public security officers on how to prevent the transmission of AIDS and venereal disease”, one of the bosses participated in the conference said.
Sharp questions were continuously put forward during the conference. “Does it mean the permission to establish red-light district and the admission of sexual transaction?” asked one of the bosses. Officials from public security sectors told him immediately that it was absolutely not the case, and prostitution and whoring of any form would be cracked down as usual.

According to the Regulation on Prevention of AIDS and STDs issued by Wuhan Municipal Government in 1999, deliberate transmission of STIs and AIDS was also a criminal behavior. This was exactly the connection point of the work respectively carried out by public security sector and health sector. According to one official in charge of implementation of 100% Condom Program in Huangpi District, “as the commercial sexual transaction is an objective existence, it would be a manifestation of responsibility for health sector to take supplementary measures to prevent the further spread of STIs and AIDS at the same time crack-down carried out by public security sectors.

This was understandable from the point of view of bosses. However, most bosses were concerned about the fact that it would means to hand over all the evidences on prostitution and whoring to public security department by coordinating with the pilots in selected places. Accordingly, staffs from 100% Condom Program Office explained to them that all relevant information was only for the analysis of situations of prevention and control of diseases.

In reality, Huangpi District Public Security Brigade enhanced the crack-down of prostitution and whoring at the same time when the Health Bureau carried out relevant pilots in selected places.

6. Breaking the ice of “distrust”.

In July, 2001, 100% Condom Program Team launched for the first time a large-scale screening. Members of the team had interviews with more than 260 employees working in recreation places within 3 months. According to the findings of investigation, the rate of condom use among service staffs working in recreation places was 60%. With regard to STIsSTIs, the rate of non-gonorrhea, syphilis as well as gonorrhea is respectively 21%, 6.9% and 2.9%. This was also the reason why 8 members of the program team felt that it was difficult to win the trusts from bosses of recreation places and service staff.
 

At the early stage when the 100% Condom Program was implemented, the biggest trouble confronted by working staff was the “distrust”. Most of bosses of recreation places were unwilling to take cooperative attitudes towards it and refused to provide relevant information on the female sex workers involved in the commercial sex transactions. This was due to the fact that they thought it was just a trap, and public security department would take interventions once relevant information was disclosed.

In view of this kind of situation, the program team requested some enlightened bosses to help with this job. As a last resort, the program team would warn individual bosses who were unwilling to take cooperative attitudes towards this issue, and requested public security sectors to take mandatory measures.

 “It is a must to adopt appropriate attitudes when dealing with them”, said the working staff of the program team. “As they are so sensitive, you should not take commanding attitudes towards them”. “As a matter of fact, you should be patient and show concerns for them". Normally, it would take one year’s time to win their trusts.

Usually, working staff would use olunch breaks to make great efforts to persuade service staff in recreation places to receive physical examination by taking with them advocacy information and devices for physical examination. At the same time, working staff would print information on the prevention of AIDS on the playing cards distributed to the service staff in recreation places. Most of service staffs acquired knowledge on the prevention of AIDS when playing cards.

7. Favorable Changes

Despite of much difficulty at the early stage, a favorable turn has taken place to the situation with the establishment of trust worthy relationship between working staff and the service staffs in recreation places.

For instance, one service staff did not believe that she was inflected with syphilis through the physical examination. Working staff conducted reexamination for her and took her to the hospital for further treatment. She felt very happy and began to have confidence in working staff of the program team when she was cured. Latter, she would help working staff with advocacy work by persuading other service staffs to receive physical examination. Such instances were numerous to enumerate.

One year after the implementation of 100% Condom Program, the rate of condom use among female sex workers in 40 selected recreation places, Baoku Hairdresser’s salon, hotels and KTV increased to 94%, and the rate of STIs decreased to 14.5%.

8. From Wuhan to the Whole Hubei Province

The very fact that the little condom could reduce the rate of inflection of STIs among female sex workers working in recreation places in Huangpi District by 50% indicated that that the promotion of 100% Condom Program in Huangpi District was effective.

In the second half of 2003, WTO performed the medium-term evaluation of the implementation of 100% Condom Program in Huangpi District. The result of evaluation was proved to be satisfactory. At the end of the same year, relevant officials from Ministry of Public Health put a high value on the pilot work in Huangpi District, Wuhan City after they heard the relevant reports, and requested governmental officials in Hubei Province to further promote the 100% Condom Program throughout the Hubei Province, so as to promote Huangpi mode in the whole Hubei Province. Hubei Province took the lead in accumulating experiences on this aspect for other regions all over the country.

In February 2004, Hubei Provincial Government requested relevant sectors to stipulated policies on the reinforce prevention of HIV/AIDS throughout the whole province. In April of the same year, Hubei Provincial Government stipulated Provisions of Hubei Provincial Government on the reinforcing AIDS prevention, requesting definitely the implementation of 100% Condom Program in 48 selected places throughout the whole province.

In an attempt to accelerate the implementation of 100% Condom Program, Hubei Province went off the beaten track by authorizing directly Wuhan Municipal Health Bureau to take charge of the supervision of implementation of 100% Condom Program in the whole province. At the end of April of the same year, professionals from disease control sectors in 48 selected places gathered together in Wuhan to receive the first training on the 100% Condom Program, including such items as basic investigation, abduction and health education. At the same time, leading officials from disease control department in each place also received the training which lasted for 2 days.

Latter, Hubei Province stipulated relevant policies, and listed the prevention of AIDS as one of the important indicators for the assessment of work efficiency of Party and Governmental leaders. In other words, it could be regarded as the adoption of system of "one ballot against then veto” to the prevention of AIDS.

In 2005, 100% Condom Program was implemented in recreation places throughout the whole Hubei Province.

9. Implementation of 100% Condom Program all over the Country

During the period from April, 2004 to April, 2005, baseline survey was carried out throughout Hubei Province, including survey of base number of recreation places, places that were suspected of being involved in sex transactions as well as the infection of STIs and AIDS among target population. At the same time, health education, peer education and physical examination were also carried out in succession.

After 100% Condom Program was implemented in 48 selected places for experiments, each place began to carry out in succession relevant work of different features according to its own conditions. Furthermore, the peer education for the purpose of accelerating the promotion of Condom Program was also carried out at each hotel and restaurant.

Although most of service staffs in hotels heard about the AIDS, they knew little of relevant preventive measures. For this purpose, small class was provided for the peer education, in which, peer educator acted as the lecturer. The teaching contents were closely related to the subject of the master training plan, and took the proactive humanist viewpoint as the start point. Through the training, the risk preventing consciousness among service staffs was enhanced. 

Dangyang: Dangyang Municipal Government organized the forum on the implementation of 100% Condom Program in recreation places as presented by each competent department, owners of 16 recreation places and representatives of service staffs. The municipal government requested each department and owner of each recreation place to support this work. Furthermore, the municipal government also distributed more than 200 cards for free physical examination to service staffs working in recreation places that were suspected of being involved in the sex transactions, requesting each service staff to receive free physical examination at disease control sectors every 3 months.

Furthermore, namelist of 27 local recreation places were clarified, and the number of people found to be engaged in sex transaction was up to 152. After the program was implemented, the monthly sales volume of condoms witnessed a significant increase with the monthly growth rate up 182.6%. The rate of use of condom among high risk population was also increased from 92.5% before the implementation of the program to 95%. More over, according to the information about the epidemic, the incidence of STIs was decreased by 12.86% as compared with that of the same period in the previous year.

Daye: It was discovered that there were 350 recreation places in urban area, among which, 150 are suspected of being involved in sex transactions. Ever since the implementation of the program, working staff of the program office has interviewed with more than 200 people, conducted face-to-face discussion with more than 3, 240 service staffs in recreation places, distributed 18, 000 condoms for free, carried out physical examinations for 362 employees working in recreation places, and has organized purposely two training courses on the prevention of AIDS for people who are suspected of being involved in the sex transactions.

Shiyan: it was discovered that there were 178 recreation places in Maojian District of Shiyan City, and there were 373 employees working in these recreation places. Furthermore, working staff of the program has also established behavioral archives, and distributed 15000 condoms. The rate of provision of condoms in hotel was increased from 28% before the implementation of the program to 96%, and 181 employees working in the recreation places received the examinations for AIDS.

Since the implementation of the program, each town, sub-district office as well as village in this district has established their own leading group for 100% Condom Program, and has established a sound mechanism in which health sectors serves as the main force with the coordination from public security, industrial and commercial and family planning units. Each sub-district office and community is responsible for its own tasks with the participation, intervention and supports from social organizations.

More over, Maojian District has also opened hot line for counseling and testing for the purpose of distributing “sister’s private conversation” contact and consultation cards and providing 24-hour consultations for employees working in recreation places.

10. Special Interview conducted by Wuhan Morning

After the experiments in selected recreation places in Huangpi District won full recognition in 2004, mediums in Wuhan City began to report the program in succession. A Journalist from Wuhan Morning specially carried out interview with leading official from Wuhan Health Bureau who is in charge of the 100% Condom Program:

Q: For what reason has Wuhan been selected as the city for trial implementation 100% Condom Program?

A: It is due to the fact that we have once done some fundamental work in Wuhan. For instances, we have once carried out survey of STIs in some recreation places in Wuhan. At the same time, the proportion of recreation places that are suspected of being engaged in sex transactions as well as the AIDS infection is not so high as compared with other places in the country. Furthermore, Wuhan has a solid foundation for trial implementation of 100% Condom Program. 

Q: If the trial implementation of 100% Condom Program was objected by so many people or in other words, if it is impossible for people to think it is acceptable?

A: At the very beginning, some people, including some leaders could not accept it. Under such circumstance, we would explain to them that this program was for the prevention of AID instead of riding with a loose rein on the sex transaction.

Q: What about the attitude of public security department at that time?

A: At that time, many people thought that the implementation of 100% Condom Program was in conflict with the elimination of the pornography. However, through communication with public security department, we found that working staff in public security department were capable of understanding this work because they knew better the actual situations.

Q: Health sector did not give advocacy to the implementation of the program until this year, and has never mentioned about it for a long time in the past. Why did the health sector adopt the strategy of “keeping silence” then?

A: After all it was just pilot implementation then. Although the promotion of use of condom in recreation places in abroad has been proved to be successful, no one had any idea of what the situation in China would be at that time. The reason for the health sector to hold the attitude of “keeping silence” was to do the job in a better way.

However, it is the time to give advocacy to the implementation of the program at present. Currently, everybody is concerned about the issue on the prevention of AIDS. Therefore, we must directly face the issue of transmission of AIDS in recreation places.

Q: At the same time, some people concern about the deluge of prostitution and whoring. How do you think of it?

A: It has been proved by facts that the promotion of use of condom in recreation places is unlikely to cause the rampancy of prostitution and whoring. On the contrary, we have noticed that more and more people begin to realize it is hazardous to maintain sex relations with numerous sexual partners after they command relevant knowledge. Limited by the low educational level, many employees working in recreation places knew little about the AIDS previously. However, they are gradually getting acquainted with the AIDS, and some of them may even consider again their choices.

Q: Are you satisfied with the effect of the pilots in selected recreation places?

A: It should be said that I am satisfied with it. Ever since Huangpi District was selected as the area for pilot implementation of 100% Condom Program, the rate of infection of STIs has decreased by 50%.

Q: What is the so-called Wuhan Mode?

A: Wuhan mode can be described as bringing into full play leading role of the government, health sectors and wining supports and coordination from public security and other sectors. The reason why this program can be successful is due to the fact that this is a public governmental behavior supported by many people.

Q: Have you met with any difficulty when promoting this program all over the city?

A: We are now promoting this measure in all the recreation places throughout the city. It is may be true that there is no sex transactions in many recreation places. However, it is necessary for us to promote the condom use and advocate safe sex behavior. For instances, as it is necessary to place condoms in each room of the hotels, we often do not have enough people do this work of high volume. This is perhaps the biggest difficulty confronted by us.

Q: How will you manage to overcome it?

A: We will try to achieve this object by bringing into full play the role of community service center. Furthermore, we will also try to recruit volunteers from the whole society.